COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX641 19394  *,,.(-..;..,...  ,1!.:-; 

RC66  .M2  Systematic  case-taki   i';;i|f  ;;^;l»i-l:f;[.ii;!;ri:-;i;'H 


RECAP 


,j;('  :j;  :(■  ■ 


■'■  (•■■i< 


M^ 


|[ 


rV!;li,-Vii^!;i- :i- 


;  ::'    ,M.i:-  ./..Ui.';!!  HnJiU  *Hflt'    sn»:;  :  ;<;;,:  ■;•:■.•■',!;  •  :', 


mm 


'■t,-'mm>^ 


!"Ke<^G 


VA^ 


ttt  %  ffitt^  0f  Neur  fork 
(£,n\it^t  af  5pIjgatmnB  and  Bnr^mnB 


Efffr^nrt  Htbrarg 


SYSTEMATIC   CASE-TAKING 


SYSTEMATIC 
CASE-TAKING 

A    PRACTICAL    GUIDE    TO    THE    EXAMINATION 
AND  RECORDING  OF  MEDICAL  CASES 


BY 

HENRY  LAWRENCE  McKISACK 

M.D.,  M.R.C.P.  LOND. 

PHYSICIAN  TO  THE  ROYAL  VICTORIA  HOSPITAL,  BELFAST 
AUTHOR  OF  'A  DICTIONARY  OF  MEDICAL  DIAGNOSIS" 


NEW  YORK 

PAUL     B.     HOEBER 
69  EAST  59TH  STREET 


1913 


..'^       *^    ^^  fl^ 


I  -^^ 


PREFACE 

Within  the  compass  of  a  small  book  I  have  attempted 
to  furnish  medical  students  with  a  systematic  guide  to 
the  methods  of  examination  involved  in  the  process  of 
case-taking.  While  it  is  certain  that  no  mere  book  can 
take  the  place  of  personal  instruction  in  the  wards  by 
the  medical  registrar  or  tutor,  it  is  equally  obvious  that 
a  methodical  syllabus  will  serve  to  add  completion  and 
co-ordination  to  the  student's  examination  of  his  case, 
and  to  his  records  of  the  same.  Of  the  first  importance 
in  such  a  work  is  a  description  of  the  various  means  of 
investigation  of  disease  ;  but  it  is  necessary,  in  order 
that  the  student  should  learn  the  relative  importance  of 
the  facts  he  elicits,  that  some  consideration  should  be 
given  to  the  various  symptoms,  and  to  their  comparative 
value  in  forming  the  necessary  diagnosis. 

I  have  therefore  amplified  the  ordinary  syllabus  of 
case-taking  into  a  short  manual,  which  not  only  indi- 
cates the  steps  to  be  taken  by  the  clinical  clerk  in  order 
to  obtain  the  information  he  has  to  record,  but  which 
also  discusses,  as  concisely  as  possible,  the  diagnostic 
significance  of  the  various  symptoms  discovered.  There 
are,  I  am  aware,  many  excellent  books  which  deal 
specially  with  the  symptoms  of  disease  and  the  methods 
of  examination  ;  but,  judging  from  my  own  experience 
as  a  clinical  teacher,  it  appears  to  me  possible  that  a 


vi  PREFACE 

small  handbook  dealing  with  the  subject  strictly  from 
the  case-taker's  point  of  view  may  prove  useful. 

With  few  exceptions,  the  methods  of  examination 
referred  to  in  this  book  are  those  which  may  be  carried 
out  in  the  ward  or  clinical  room  of  a  hospital ;  the  more 
elaborate  bacteriological  and  pathological  investigations 
cannot  be  described  in  a  manual  for  clinical  clerks, 
though  the  results  of  such  pathological  examinations 
must  be  duly  noted  in  the  case-sheet. 

The  scope  of  this  book  being  limited  to  the  examina- 
tion and  diagnosis  of  those  affections  which  are  usually 
treated  in  the  medical  wards  of  a  general  hospital,  those 
conditions  which  belong  to  the  surgical  and  special 
departments  are  only  referred  to  when  they  have  some 
diagnostic  relation  to  cases  of  internal  medicine. 

H.  L.  McKISACK. 
Belfast, 

March,  19 12. 


CONTENTS 

PAGE 

Introduction      -  -  -----  ix 

CHAPTER  I 

PRELIMINARY   INQUIRIES 

Outline  of  the  method  recommended  for  case-taking — 
Family  history — Personal  history — History  of  the 
present  affection — ^Symptoms,  subjective  and  objec- 
tive— Pain     ------  I 

CHAPTER  n 

GENERAL  EXAMINATION 

Aspect — Eruptions — Posture — Gait — Shape  and  size  of  the 
body  —  The  tongue  —  Temperature  —  Respiration — 
Pulse  ._----  15 

CHAPTER   III 

THE  THORAX 

Topography — Methods    of    examination — Shape    of    the 

chest  -------36 

CHAPTER  IV 

RESPIRATORY  SYSTEM 

Dyspnoea — Disturbed  rhythm  of  respiration — Cough — 
Alterations  in  the  voice — Vocal  fremitus — Percussion 
— Auscultation — Breath  sounds — Voice  sounds — Ad- 
ventitious sounds — Examination  of  the  sputum       -  41 

vii 


viii  CONTENTS 

CHAPTER  V 
CIRCULATORY  SYSTEM 

PAGE 

Movements  of  the  chest  wall — Area  of  cardiac  dulness — 
Displacements  of  the  apex-beat — Thrill — The  sounds 
of  the  heart — Adventitious  sounds — Murmurs — Fric- 
tion sounds — Examination  of  the  arteries,  veins,  and 
capillaries      ------  62 

CHAPTER  VI 

BLOOD 
Blood  examination — The  Glandular  System        -  -  78 

CHAPTER   VII 

THE  ABDOMEN 

Topography — Aspect  and  surface  markings — Palpation — 
Percussion — Auscultation — The  stomach  and  its  con- 
tents —  Intestines — Liver — Spleen — Kidneys — Pelvic 
organs  .-_--_  84 

CHAPTER  VIII 

EXAMINATION  OF  THE  URINE 

Method  of  examination — Naked-eye  examination  (colour, 
translucency,  odour,  reaction,  density,  quantity) — 
Chemical  examination  (albumin,  sugar,  diacetic  acid, 
urea,  bile,  blood,  uric  acid,  indican,  chlorides) — Micro- 
scopical examination  (pus,  casts,  epithelium,  urates, 
phosphates,  oxalates,  micro-organisms,  etc.)    -  -       99 

CHAPTER  IX 

NERVOUS  SYSTEM 

Routine  method  of  examination — Defects  of  movement — 
Loss  of  power — Increased  muscular  action — Disorderly 
movements — Reflexes — S  ensor y  disturbances  —  Psy- 
chical functions         -  -  -  -  -         116 

Appendices  -  -  -  -  -  -        145 

Index       -.-__--         159 


INTRODUCTION 

In  attempting  the  diagnosis  of  a  medical  case,  one 
has  to  make  a  collection  of  all  the  facts  bearing  on 
the  condition  of  the  patient.  The  discrimination  be- 
tween those  facts  which  are  relevant  to  the  case  in  hand 
and  those  which  should  not  influence  one's  judgment 
upon  it,  is  not  always  an  easy  task  to  the  experienced, 
and  to  the  novice  is  an  impossibility.  It  is  there- 
fore universally  the  practice  in  medical  schools  to  in- 
struct the  student  to  collect  what  may  seem  an  unduly 
large  mass  of  information  regarding  the  case  under  ex- 
amination, and  to  arrange  and  formulate  his  harvest  of 
facts  in  a  definite  and  methodical  manner.  At  first,  no 
doubt,  there  will  be  included  in  the  case-sheet  unneces- 
sary and  incorrect  statements,  but  even  from  an  early 
stage  of  his  clinical  clerkship  the  student,  if  he  be  pos- 
sessed of  ordinary  powers  of  observation  and  industry, 
and  if  he  follow  the  recognized  rules  of  case-taking,  will 
be  able  to  present  a  fairly  complete  and  accurate  account 
of  his  cases.  As  his  experience  widens,  he  will  be  able 
safely  to  omit  a  certain  proportion  of  the  details  which 
at  first  he  must  include.  Systematic  case-taking  is  the 
only  safe  way  to  learn  thoroughly  the  art  of  diagnosis, 
and  the  time  spent  in  this  occupation  is  perhaps  the 
best  investment  the  student  can  make  of  his  energy. 
In  the  course  of  his  examination  the  student  may  have 

ix 


X  INTRODUCTION 

to  put  the  patient  to  some  inconvenience.  This  may  be 
unavoidable,  but  it  is  one's  duty  to  treat  him  with  all 
possible  consideration  and  patience,  bearing  in  mind  that 
what  seems  to  us  to  be  an  inoffensive  procedure  or  inquiry 
may  to  the  uninstructed  invalid  cause  apprehension  or 
confusion. 

Two  means  of  investigation  are  open  to  the  student, 
and  both  have  to  be  taken  advantage  of  to  the  fullest 
extent — namely,  interrogation  of  the  patient  (and  of  his 
friends,  if  necessary)  and  physical  examination.  All  that 
the  patient  has  to  tell  must  be  seriously  considered,  but 
the  examiner  has  ample  scope  for  the  exercise  of  his 
judgment  as  to  how  much  is  worthy  of  recording.  Care 
must  be  taken  to  avoid  being  misled  by  inaccuracies  of 
description  or  of  fact.  Statements  involving  a  diagnosis 
should  be  recorded  with  some  indication  that  it  is  un- 
verified information — quotation  marks  serve  the  pur- 
pose. As  far  as  possible,  leading  questions  should  be 
avoided,  but  at  times  they  are  necessary.  The  state  of 
the  patient's  intellect,  which  will  engage  the  attention 
of  the  student  more  closely  when  the  nervous  system  is 
under  special  examination,  should  even  at  an  early  stage 
be  carefully  considered,  in  order  to  judge  as  to  the  value 
df  the  information  obtained  from  him. 

The  physical  examination  should  be  comprehensive, 
and  should  be  exhaustive  in  that  system  which  one  has 
reason  to  believe  is  especially  involved. 


SYSTEMATIC   CASE-TAKING 

CHAPTER  I 

PRELIMINARY   INQUIRIES 

Outline  of  the  method  recommended  for  case-taking — Family 
history — Personal  history — History  of  the  present  affection 
— Symptoms,  subjective  and  objective — Pain, 

Outline  of  the  Method  recommended  for  Case-Taking. — 

Having  collected  all  the  information  possible  on  the 
patient's  family  history,  personal  history,  and  the 
history  of  the  complaint  for  which  he  has  sought  advice, 
a  general  survey  of  the  present  state  of  the  individual  is 
to  be  made  on  the  lines  suggested  in  Chapter  11.  The 
different  systems  are  then  to  be  separately  examined.  In 
each  the  subjective  and  objective  symptoms  are  to  be 
described,  special  attention  being  given  to  the  organs 
which  are  obviously  at  fault.  It  is  advisable  to  take  up 
each  system  in  rotation,  and  always  in  the  same  order. 
The  following  routine  will  be  found  convenient :  (i)  The 
Thorax,  comprising  the  respiratory  and  circulatory 
systems ;  (2)  the  Blood ;  (3)  the  Glandular  system 
(lymphatic,  thyroid,  spleen)  ;  (4)  the  Abdomen,  includ- 
ing the  alimentary  system  and  the  pelvic  organs ; 
(5)  the  Urinary  system  ;  (6)  the  Nervous  system. 

An  important  part  of  the  clinical  clerk's  duty  is  to 
record  the  treatment  of  the  case  and  its  result,  taking 


2  SYSTEMATIC  CASE-TAKING 

notes  at  short  intervals  (not  less  than  twice  weekly)  on 
the  course  of  the  malady.  The  diagnosis  arrived  at, 
and  the  issue,  are  to  be  recorded.  In  fatal  cases,  if  a 
post-mortem  examination  be  held,  the  condition  found 
is  to  be  noted  on  the  case-sheet. 

After  having  noted  the  name,  age,  address,  occupa- 
tion, and  condition,  whether  married  or  single,  a  short 
preliminary  statement  should  be  made,  relating  what 
the  patient  complains  of,  or  any  outstanding  circum- 
stances which  induced  him  to  seek  medical  advice. 

Family  History. — It  is  always  a  difficult  task  to  obtain 
accurate  or  reliable  information  on  this  subject,  and 
among  hospital  patients  it  is  often  impossible.  By  the 
exercise  of  perseverance  and  tact  it  is,  however,  usually 
possible  to  gain  some  useful  information  concerning  the 
hereditary  tendencies  of  the  individual.  The  effect  of 
heredity  is  shown  chiefly  by  the  capacity  of  the  indi- 
vidual to  combat  the  innumerable  disturbing  influences 
which  are  constantly  on  the  point  of  interfering  with  our 
tissues  and  organs  and  their  functions.  The  man  who 
has  inherited  a  defective  power  of  resistance  to  certain 
disturbing  influences  often  proves  on  careful  inquiry,  to 
have  had  other  near  relatives  similarly  vulnerable.  In 
many  cases  this  susceptibility  forms  a  widespread  defect 
producing  lesions  of  differing  types,  involving,  however, 
structures  of  physiological  or  anatomical  unity.  The 
best  example  of  this  is  seen  in  the  group  of  diseases  of 
the  nervous  system  which  may  occur  in  a  variety  of 
forms  in  a  family  circle.  Thus  one  member  of  the  con- 
nection may  be  epileptic,  another  may  show  criminal 
or  alcoholic  tendencies,  another  insanity  or  hysteria. 
Again,  several  members  of  a  family  may  show  a  defec- 
tive resistance  to  the  attacks  of  the  tubercle  bacillus, 
and  various  forms  of  tuberculosis  are  met  with.    Defects 


PRELIMINARY  INQUIRIES  3 

of  metabolism,  renal  disease,  joint  affections,  and  arterial 
changes,  with  consequent  heart  lesions,  form  another 
group  of  diseases  often  found  occurring  in  members  of 
a  family  in  whom  the  so-called  gouty  diathesis  is  in- 
herited. In  some  families  cancer  seems  to  occur  with 
more  than  common  frequency.  The  influence  of  heredity 
in  cancerous  affections  is,  however,  denied  by  many 
authorities.  A  susceptibility  to  infection  of  the  com- 
moner exanthemata  is  at  times  noticed  in  families,  while 
in  others  the  resisting  power  is  unusually  effective.  Of 
skin  diseases,  ichthyosis  is  perhaps  the  best  instance  of 
heredity.  In  psoriasis,  eczema,  scrofuloderma,  leprosy, 
and  syphilis,  the  hereditary  influence  has  to  be  considered. 
Haemophilia  is  a  distinctly  hereditary  affection,  occurring 
almost  exclusively  in  males  (about  go  per  cent,  of  the 
cases  are  males),  who  transmit  the  tendency  to  bleed 
through  non-bleeding  daughters  to  male  posterity.  In 
certain  organic  diseases  of  the  nervous  and  muscular 
tissues  the  influence  of  heredity  is  undoubted.  Among 
these  may  be  mentioned  Friedreich's  ataxia,  cerebellar 
heredo- ataxia  (Marie),  progressive  neural  muscular 
atrophy,  progressive  muscular  dystrophies,  Thomsen's 
disease — all  rare  affections. 

Personal  History. — Under  this  heading  the  student 
must  seek  all  the  information  bearing  on  the  history  of 
the  individual  which  can  in  any  way  modify  the  course 
or  issue  of  his  malady.  These,  omitting  family  history, 
which  has  already  been  considered,  are,  shortly — (i)  Age; 
(2)  sex ;  (3)  occupation ;  (4)  environment ;  (5)  habits, 
both  personal  and  physiological  (the  latter,  in  the  case 
of  females,  especially  concerning  the  reproductive  organs) ; 
and,  lastly  (6),  an  account  of  any  illness  from  which  he 
may  have  suffered  before  the  onset  of  the  present  affec- 
tion. 


4  SYSTEMATIC  CASE-TAKING 

1.  Age. — The  age  of  the  patient  influences  not  only 
the  course,  but  also  the  incidence  of  disease.  In  infancy 
and  childhood  the  power  of  resistance  to  many  disturbing 
factors  may  be  defective ;  hence  the  digestive,  the 
respiratory,  and  the  nervous  systems  are  frequently 
affected.  Digestive  disturbances,  rickets,  laryngeal  and 
bronchial  catarrhs,  infantile  palsies,  and  chorea  are 
among  the  results.  Imperfect  resistance  also  gives  rise 
to  the  exanthemata  and  to  tuberculosis,  which  in  child- 
hood is  likely  to  be  seated  in  bones,  joints,  and  lymphatic 
glands.  In  the  adolescent  period  tubercular  affections 
are  still  common,  and  especially  phthisis,  for  which  this 
is  the  favourite  age  ;  acute  rheumatism  (causing  greater 
damage  to  the  heart  in  earlier  than  in  later  years)  ; 
chlorosis  ;  hysteria  ;  gastric  ulcer.  By  middle  age  the 
subject  has  acquired  immunity  from  many  affections,  so 
that  his  liability  to  infections  of  all  descriptions  is  dimin- 
ished, though  by  no  means  abolished.  On  the  other 
hand,  his  tissues  have  a  tendency  to  undergo  degenera- 
tive changes,  and  we  find  a  large  group  of  affections 
connected  with  changes  in  the  arteries  and  defects  of 
metabolism — viz.,  arterio-sclerosis,  aneurism,  cardio- 
sclerosis, gout,  renal  calculus,  gall-stones,  cancer,  pro- 
found anaemias  and  blood  diseases,  and  insanity.  Ter- 
tiary syphilitic  phenomena  and  the  late  parasyphilitic 
diseases — e.g.,  locomotor  ataxia,  general  paresis — now 
appear,  and,  generally  speaking,  the  results  of  occupa- 
tion, habits,  and  hardships,  are  met  with  most  frequently 
in  this  period  of  life.  With  the  arrival  of  old  age  we 
look  for  a  further  development  of  the  degenerations. 

2.  Sex. — In  childhood  sex  has  but  little  influence  on 
the  incidence  or  course  of  disease,  except  in  the  case  of 
haemophilia,  \yhich  commonly  shows  itself  in  boys  in  the 
first  or  second  year.     From  puberty  onward  consider- 


PRELIMINARY  INQUIRIES  5 

able  difference  is  noticed  between  the  sexes  in  respect  to 
disease.  Gastric  ulcer,  chlorosis,  and  exophthalmic  goitre, 
are  commoner  in  the  adolescent  female.  In  middle  life 
women  are  more  liable  than  men  to  gall-stones,  cancer 
(chiefly  owing  to  the  frequency  of  breast  and  uterine 
disease),  osteo- arthritis,  neurasthenia,  myxoedema,  and 
movable  kidney.  At  this  period  men  suffer  more  than 
women  from  the  effects  of  vicious  habits,  exposure, 
traumatism,  overexertion,  and  dangerous  occupations  ; 
hence  they  are  especially  liable  to  gout,  arterio-sclerosis, 
aneurism,  degenerative  heart  affections,  cirrhosis  of  the 
liver,  locomotor  ataxia,  and  syphilitic  lesions  generally. 

3.  Occupation.  —  The  broad  distinction  between  an 
active  and  a  sedentary  individual  often  depends  upon 
his  occupation.  Among  hospital  patients  this  is  almost 
always  the  case,  as  in  this  class  exercise  is  rarely  taken 
for  its  own  sake.  The  beneficial  effects  of  an  active  life 
need  not  be  here  insisted  upon  ;  those  who  live  an  active, 
but  not  too  strenuous,  life  are  in  the  best  state  to  offer 
an  effective  resistance  to  disease  of  all  kinds.  Certain 
occupations  favour  the  development  of  morbid  pro- 
cesses. Inhalation  of  dust,  consisting  of  irritant  par- 
ticles, may  cause  lung  affections,  such  as  knife-grinders' 
phthisis  or  flax- dressers'  bronchitis.  Glanders,  anthrax, 
lead-poisoning,  result  from  exposure  to  the  respective 
poisons.  Writers'  cramp,  miners'  nystagmus,  miners' 
elbow,  housemaids'  knee,  are  examples  of  disorders 
directly  due  to  occupation. 

4.  Environment. — Does  the  patient  live  in  the  country 
or  in  a  town  ?  If  in  the  latter,  is  he  a  slum  denizen  or 
an  inhabitant  of  a  more  healthy  urban  district  ?  It 
would  be  interesting  to  ascertain,  if  it  were  possible, 
whether  his  house  is  clean,  with  fair  sanitary  arrange- 
ments, and  if  his  bedroom  is  capable  of  ventilation  ;  for 


6  SYSTEMATIC  CASE-TAKING 

it  is  the  absence  of  these  conditions  which  gives  rise  to 
the  surprising  amount  of  ill-health,  and  particularly  of 
tuberculosis,  which  one  meets  with  in  country-bred 
people.  Damp  climates,  marshy  districts,  malarial 
regions,  tropical  countries,  goitre  localities,  all  exercise 
an  influence  on  the  individual  and  on  his  maladies. 

5.  Habits. — In  this  connection  we  investigate  first 
his  daily  life.  Is  he  a  regular-living  man,  or  is  he  of 
dissipated  or  irregular  tendencies  ?  The  answer  to  this 
question  is  of  the  utmost  importance  in  forming  a  prog- 
nosis, as  the  latter  class  is  uninsurable.  Is  he  a  good 
sleeper,  or  is  he  subject  to  insomnia  ?  Has  he  any 
recreations,  and,  if  so,  what  form  do  they  take  ?  The 
habits  of  his  body  are  to  be  ascertained — the  regularity 
or  otherwise  of  the  bowels  and  bladder  evacuation.  In 
females  the  menstrual  function  and  the  reproductive 
history,  if  any,  are  to  be  recorded. 

6.  Previous  Illnesses. — The  occurrence  of  certain 
diseases — e.g.,  influenza,  rheumatism,  gout,  chorea,  ton- 
sillitis, asthma,  and  erysipelas — ^suggests  a  recurrence  of 
these  affections.  The  exanthemata,  on  the  contrary, 
usually  protect  the  subject  from  a  second  attack.  In 
some  diseases  it  is  the  subsequent  developments  or 
sequelae,  rather  than  a  recurrence  of  the  complaint  itself, 
which  we  must  look  for.  For  example,  rheumatism  and 
chorea  suggest  endocarditis,  scarlatina  suggests  Bright 's 
disease,  gonorrhoea  causes  arthritis,  syphilis  is  the  pre- 
cursor of  many  affections  of  the  nervous  system  and 
elsewhere,  pleurisy  may  be  the  starting-point  of  a  later- 
developing  phthisis. 

History  of  the  Present  Affection. — ^We  now  first  ap- 
proach the  actual  disease  from  which  the  patient  is 
suffering,  and  the  three  chief  items  of  information  which 
we  try  to  elicit  from  him  or  from  his  friends  are — 


PRELIMINARY  INQUIRIES  7 

(i)  When,  (2)  How,  and  (3)  Why  did  the  malady  attack 
him. 

1.  When  did  he  first  notice  anything  amiss  ?  A  cor- 
rect reply  to  this  question  is  absolutely  necessary,  and 
is  often  difficult  to  obtain.  The  patient  must  be  en- 
couraged to  recall  when  he  first  felt  ill,  or  when  he 
left  off  work,  or  when  his  friends  noticed  him  to  be 
ailing. 

2.  The  answer  to  the  query  How  he  was  affected  will 
inform  us  of  the  mode  of  onset  and  course  of  the  disease. 
Was  it  sudden  or  gradual  ?  Had  he  pain  or  loss  of 
power  ?     Was  he  feverish  ? 

3.  Why  he  was  attacked  by  the  disease  is  more  than 
we  can  reasonably  hope  to  learn  from  the  patient.  We 
may,  however,  find  some  useful  hints  in  his  theories  as 
to  the  cause  of  his  illness.  There  may  be  a  history  of 
exposure  to  cold  and  wet,  or  indiscretion  in  diet,  an 
injury,  or  exposure  to  infection. 

The  first  of  these  three  questions  is  the  most  essential. 
Every  possible  fact  concerning  the  dates  of  commence- 
ment and  of  any  change,  relapse,  or  exacerbation,  must 
be  recorded. 

The  Present  Condition. — ^We  have  now  to  fully  inform 
ourselves  by  inquiry  and  by  observation  as  to  the  actual 
state  of  the  patient.  All  the  phenomena  produced  by 
morbid  states  and  processes  are  spoken  of  as  symptoms. 
Those  of  which  the  patient  is  conscious,  but  which  the 
case-taker  cannot  verify  by  his  own  observation,  are 
termed  subjective  symptoms  ;  those  which  the  observer 
can  demonstrate  by  the  various  means  of  examination 
are  called  objective  symptoms  or  physical  signs.  The 
former  are  less  valuable  than  the  latter,  as  the  patient's 
sensations  are  often  unreliable.  In  many  cases,  how- 
ever, one  gains  valuable  information  by  investigating 


8  SYSTEMATIC  CASE-TAKING 

carefully  the  subjective  symptoms,  and  they  must  never 
be  neglected. 

There  are  a  number  of  s5miptoms  which  are  mainly 
subjective,  but  which  may  also  be  recognized  by  the 
observer.  For  example,  loss  of  muscular  power  is  ex- 
perienced by  the  patient,  but  careful  examination  will 
usually  demonstrate  it.  Vertigo  is  felt,  and  also  notice- 
able to  the  b^^stander.  Dyspnoea,  cough,  nausea,  and 
vomiting,  may  also  be  mentioned  in  this  connection.  It 
is  the  disorders  of  sensation  that  constitute  the  chief  sub- 
jective s^TQptoms,  and  these  are,  briefly,  pain ;  ex- 
aggerated common  sensibility  {hyper cBsthesia)  ;  defective 
consciousness  of  sensory  stimuli,  involving  the  apparatus 
producing  pain,  heat,  cold,  common  sensation,  muscular 
and  joint  sensibility,  and  the  special  senses  (sight, 
hearing,  taste,  and  smell)  ;  abnormal  sensations  (farces- 
tJiesia),  such  as  tickling,  pricking,  or  tingling  sensations  ; 
and  various  vague  discomforts,  as  the  sensation  of  a 
lump  in  the  throat,  or  fulness  or  tension  or  constriction 
in  some  part  of  the  body.  Lastly,  a  general  indescrib- 
able discomfort  or  "  malaise  "  may  be  experienced. 

Subjective  Symptoms. — Before  proceeding  to  the  ex- 
amination of  the  patient,  some  record  of  the  subjective 
S3miptoms  must  be  attempted,  and  the  student  has  to 
exercise  patience  and  ingenuity  in  arriving  at  a  true 
estimate  of  the  patient's  sufferings. 

Pain. — This  is  the  commonest  of  the  subjective  symp- 
toms, and  deserves  a  somewhat  detailed  consideration. 
The  pain  which  is  elicited  by  the  examiner  on  pressing, 
rubbing,  moving,  or  knocking  the  region — that  is,  tender- 
ness— is  really  an  objective  s3Tnptom,  but  for  conveni- 
ence' sake  is  best  discussed  here. 

General  pain,  involving  the  greater  part  of  the  body, 
s  found  in  many  fevers,  and  is  especially  characteristic 


PRELIMINARY  INQUIRIES  g 

of  influenza  and  smallpox  ;  also  of  acute  and  chronic 
rheumatism. 

Localized  pain  may  be  an  aid  in  identifying  the  affected 
region,  but  it  is  often  referred  to  a  region  quite  remote 
from  the  source  of  the  suffering.  This  is  particularly 
the  case  in  disease  of  the  viscera,  when  pain  may  be  felt 
in  a  superficial  spot  or  area.  This  is  often  best  elicited 
by  stroking  the  surface  with  a  blunt  point — e.g.,  a  pencil. 
Here  the  stimulus  from  the  diseased  organ,  proceeding 
to  the  sensory  centre,  spreads  into  neighbouring  sensory 
paths  in  the  cord,  and  is  referred  to  the  region  from 
which  the  latter  proceed.  A  summary  of  the  regional 
pains  and  of  their  significance  is  as  follows  : 

Headache  (Cephalalgia). — Varieties  :  Migraine  (sick 
headache,  bilious  headache,  hemicrania)  usually  in- 
volves the  branches  of  the  fifth  nerve,  often  begins  with 
visual  phenomena.  Neuralgia,  also  one-sided,  darting, 
often  periodical.  Dyspepsia  and  constipation  :  dull, 
throbbing,  chiefly  frontal,  supra-orbital  and  bilateral. 
Neurasthenia  :  tense,  constricting,  often  vertical,  worst 
in  morning,  may  be  stabbing  (clavus  hystericus) .  Anaemia, 
resembles  that  of  neurasthenia.  Abdominal  organs,  and 
especially  female  organs  of  generation,  when  diseased, 
often  cause  sharp  occipital  headache.  Affections  of 
eyes,  nose,  and  naso-pharynx  :  supra-orbital  pain,  often 
temporal  or  occipital.  Intracranial  disease  :  oftenest 
occipital,  but  may  be  general ;  rarely  a  guide  to  locality 
of  disease.  Syphilis  (excluding  intracranial  growths)  : 
nocturnal  pain,  often  occipital.  Fever  :  in  typhoid  a 
frontal,  vertical,  or  general  headache  characterizes  the 
first  week.  Toxic  states  :  nephritis  (uraemia),  chronic 
poisoning  by  alcohol,  nicotine,  lead,  mercury,  or 
impure  air.  Disease  of  cranial  bones  causes  severe 
pain.     If  the  disease  is  situated  near  the  ear,  usually 


lo  SYSTEMATIC  CASE-TAKING 

tubercular ;  other  regions,  especially  frontal,  often 
syphilitic. 

Pain  in  the  Face. — In  addition  to  those  conditions  just 
referred  to  under  Headache,  carious  teeth,  tonsillitis, 
disease  of  facial  bones  (caries,  cancer,  antrum  disease), 
and  of  the  tongue,  temporo-maxillary  joint  (rheumatism, 
osteo- arthritis,  or  gonorrhoea!  arthritis),  and  mumps, 
may  cause  severe  facial  pain. 

Pain  in  the  Neck. — Front  and  sides  usually  inflamma- 
tions—  adenitis  commonest  —  also  tonsillitis,  mumps, 
pharyngitis,  foreign  body  or  cancer  in  throat,  cervical 
caries,  myalgia.  Back  of  neck :  myalgia  (muscular 
rheumatism)  commonest,  cervical  caries,  meningitis, 
myelitis,  tetanus. 

Pain  in  the  Throat. — A  very  common  seat  of  infection, 
causing  painful  inflammatory  lesions — e.g.,  acute  and 
chronic  pharyngitis,  follicular  and  phlegmonous  ton- 
sillitis, scarlet  fever,  influenza,  mumps,  diphtheria,  ulcer 
of  the  fauces  (follicular,  cancerous,  tubercular,  syphilitic, 
or  traumatic) .     (See  Appendix  I.) 

Pain  in  the  Thorax. — Upper  anterior  part  (supra-  and 
infra-clavicular  regions) :  pleuritic  pain — often,  but  not 
always,  tubercular ;  gastric  and  diaphragmatic  irrita- 
tion is  often  felt  here.  Behind  sternum :  Digestive  dis- 
order (gnawing  soreness  and  weight) ;  bronchial  and 
tracheal  catarrh.  Less  common  are — angina  pectoris 
(oppressive  and  suffocating  pain,  usually  extending  to 
left  shoulder  and  arm),  disease  of  sternum  or  vertebrae 
(caries  or  syphilis),  aneurism  (pain  often  in  back), 
mediastinal  tumours,  pericarditis.  In  female  breast: 
disease  of  that  organ  (mastitis,  cyst,  cancer,  cracked 
nipple),  during  menstruation  and  pregnancy,  hysteria, 
disease  of  ovaries  and  uterus.  In  precordial  region  : 
gastric  neurosis,  catarrh,  and  flatulence ;  ulcer  ;  cancer 


PRELIMINARY  INQUIRIES  ii 

of  stomach  ;  pericarditis  (often  stabbing  and  sharp,  and 
tender  over  lower  part  of  sternum)  ;  aortic  disease,  with 
which  (or  even  without  obvious  cardiac  disease)  may  be 
associated  angina  pectoris ;  pseudo-angina,  resembling 
true  angina  (in  anaemia,  hysteria,  debility).  In  axillary 
and  infra-axillary  regions  :  pleurisy  (sharp,  stabbing, 
aggravated  by  movement  or  active  breathing),  pneu- 
monia (pain  due  to  pleurisy),  pleurodynia  (muscular 
rheumatism),  intercostal  neuralgia,  herpes  zoster  (pain 
may  be  the  first  symptom,  and  is  neuralgic  in  character), 
flatulence,  constipation,  stomach  disorders,  may  cause 
pain  here.  In  the  shoulders  :  rheumatism  (articular  or 
muscular)  ;  affections  of  liver,  stomach,  bowels,  aorta  ; 
pleurisy,  apical  pneumonia,  and  phthisis.  In  infra- 
scapular  regions  :  pleurisy,  pneumonia,  stomach,  spleen, 
and  liver  affections,  movable  kidney  (commonest  on 
right  side),  gastric  ulcer  (usually  close  to  left  side  of 
eleventh  and  twelfth  dorsal  vertebrae),  renal  calculus 
(one-sided  and  aggravated  by  percussion),  lumbago, 
acute  nephritis,  constipation,  flatulence.  In  inter- 
scapular region  :  stomach  affections  ;  caries  of  the  ver- 
tebrae (commonest  in  this  region  of  spinal  column)  ; 
myalgia,  or  muscular  rheumatism,  is  less  common  here 
than  in  shoulders  or  loins ;  aneurism  of  aorta  (boring, 
persistent  pain). 

Pain  in  the  Vertebral  Column. — Lateral  curvature  (sco- 
liosis) causes  an  ache  in  the  back  ;  hysteria  causes  pain 
or  tenderness  on  pressure  over  vertebral  spines  ;  caries  of 
the  vertebrae,  commonest  in  middle  or  lower  dorsal 
regions,  painful  on  pressure,  and  may  produce  symp- 
toms of  pressure  on  spinal  cord  and  irritation  of  nerve 
roots  ;  fevers — e.g.,  influenza,  smallpox  ;  spinal  affections 
— e.g,,  meningitis,  myelitis,  locomotor  ataxia,  tetanus, 
syringomyelia  ;  a  variety  of  abdominal  diseases,  such  as 


12  SYSTEMATIC  CASE-TAKING 

gastric  ulcer,  cancer  of  the  liver,  inflammation  and  cancer 
of  the  pancreas,  affections  of  the  uterus  and  other  pelvic 
organs  ;  aneurisms  of  the  thoracic  or  abdominal  aorta  ; 
mediastinal  tumours.  Pain  over  the  sacrum  and  coccyx 
may  be  due  to  rectal  and  anal  irritation  (cancer,  piles, 
fissure  or  fistula),  or  to  affections  of  other  pelvic  organs 
(prostatitis,  sexual  excesses,  uterine  disease,  ovaritis, 
pelvic  cellulitis)  ;  to  sciatica,  sacro-iliac  disease,  hip-joint 
disease,  neuralgia  of  the  coccyx  (coccygodynia) . 

Pain  over  the  spine  may  be  elicited  by  pressure,  per- 
cussion, or  by  the  application  of  heat.  This  especially 
applies  to  inflammations  of  the  spinal  column  and  canal 
— e.g.,  meningitis,  spondylitis,  myelitis. 

Pain  in  the  Abdomen. — In  the  hypochondria  :  movable 
kidney  (dragging,  sickening  character,  worse  in  upright 
posture),  renal  calculus  (severe,  colicky,  radiating  down- 
wards towards  the  groin,  testicle,  or  pubes) ;  pleurisy 
>  (pain  may  be  referred  to  epigastric,  umbilical,  or  lumbar 
regions)  ;  on  right  side  :  liver  affections  (active  and 
passive  congestion,  cirrhosis,  cancer,  abscess),  gall-stones 
(paroxysmal,  severe,  in  epigastric,  umbilical,  and  lumbar 
regions)  ;  on  left  side  :  gastric  catarrh,  ulceration,  flatu- 
lence, enlargement  of  spleen,  and  perisplenitis.  In  the 
epigastrium  :  stomach  affections  chiefly  ;  a  sharp,  cutting 
pain,  in  one  definite  spot,  felt  soon  after  food,  with  or 
without  a  corresponding  painful  spot  in  the  back,  sug- 
gests gastric  ulcer  ;  a  more  persistent  pain,  also  aggra- 
vated by  food,  is  felt  in  gastric  cancer  ;  dyspepsia  causes 
pain  similar  to  gastric  ulcer,  but  less  localized  and  less 
cutting  in  character  ;  duodenal  ulcer  gives  pain  later  in 
the  digestive  process,  localized  usually  to  the  right  and 
somewhat  above  the  umbilicus  ;  gall-bladder  and  liver 
affections  (see  above)  may  be  felt  here,  as  also  the  pain 
of  appendicitis  early  in  the  attack  ;  pneumonia,  diaphrag- 


PRELIMINARY  INQUIRIES  13 

matic  irritation  (pleurisy,  violent  coughing,  or  vomiting), 
aneurism,  disease  of  pancreas  or  of  vertebrae,  are  less 
frequent  causes  of  epigastric  pain.  In  lumbar  and  iliac 
regions :  affections  of  large  intestine — e.g.,  faecal  accumu- 
lation (chiefly  left  iliac),  colic,  stricture  of  gut,  volvulus 
(often  left-sided  or  umbilical),  colitis,  appendicitis f  at 
first  pain  is  epigastric  or  general  over  abdomen,  later 
restricted  to  right  iliac  fossa  (McBurney's  point),  where 
the  chief  tenderness  is  located};  intussusception  (often 
umbilical  pain  also)  ;  typhoid  fever  usually  causes  slight 
pain  in  right  iliac  fossa  ;  floating  kidney  is  commonest 
on  right  side,  causing  pain  in  iliac  or  umbilical  region  ; 
hernia ;  varicocele ;  renal  colic  (see  above)  ;  pelvic 
disease  ;  tubercular  or  other  ulceration  of  the  bowel. 
In  the  umbilical  region :  cancer  or  tuberculosis  of  omen- 
tum ;  umbilical  hernia  ;  strangulated  inguinal  or  femoral 
hernia  often  causes  pain  to  be  chiefly  umbilical,  as  is 
also  the  case  at  times  in  perforated  gastric  ulcer  and 
appendicitis  in  the  beginning  of  an  attack  ;  gall-stones, 
floating  kidney,  colic  of  intestinal  irritation  and  of  lead- 
poisoning,  all  cause  umbilical  pain.  In  the  hypogastric 
region :  urinary  bladder  affections  (cystitis,  stone, 
tubercle,  cancer),  diseases  of  female  genital  organs,  and 
inflammation  of  pelvic  tissues.  In  the  abdomen 
generally :  peritonitis  (with  rigidity  of  abdominal 
muscles,  tenderness,  and  distension)  ;  most  of  the  pain- 
ful conditions  already  mentioned  as  occurring  in  one  or 
other  region  of  abdomen  may  at  times  be  generalized  ; 
the  pains  due  to  irritant  poisoning,  cholera,  gastric 
crises  of  locomotor  ataxia,  and  Dietl's  crises  (in  movable 
kidney),  are  usually  felt  all  over  the  abdomen. 

Pain  in  the  Gluteal  Region. — Sciatica  (dull,  boring 
pain,  with  acute  attacks,  one-sided,  pa;n  and  tenderness 
over  trunk  and  distribution  of  nerve),  hip-joint  disease, 


14  SYSTEMATIC  CASE-TAKING 

sacro-iliac  disease,  lightning  pains  of  locomotor  ataxia 
(may  be  in  leg,  but  usually  worse  in  buttocks  and  back 
of  thighs),  disease  of  pelvic  organs.  Pain  in  external 
genitals :  usually  due  to  local  disease  ;  in  testicle  may 
indicate  stone  in  kidney  or  ureter,  or  may  be  due  to 
neuralgia  or  neurasthenia ;  at  the  point  of  the  penis, 
pain  may  result  from  stone  in  the  bladder,  but  more 
commonly  from  local  disease.  Pain  in  the  anus :  piles 
cause  a  dull,  throbbing,  heavy  pain,  while  that  from 
fissure  is  usually  sharp  and  acute.  Pain  in  the  groin 
may  be  due  to  renal  colic,  intestinal  colic,  hernia,  vari- 
cocele, enlarged  inguinal  glands,  neuralgia,  pelvic 
disease,  etc. 

Pain  in  the  Arms  and  Legs,  when  not  the  result  of  local 
disease  (phlebitis,  bone  and  joint  affections,  etc.),  may  be 
a  portion  of  general  medical  disorders :  rheumatism  ; 
locomotor  ataxia  (usually  in  legs  and  trunk)  ;  gout  and 
osteo-arthritis  (commonly  in  hands) ;  peripheral  neuritis, 
etc. 

The  remaining  disorders  of  sensation,  as  well  as  other 
subjective  symptoms  referred  to  above,  will  be  more 
conveniently  discussed  later,  when  the  examination  of 
the  nervous,  respiratory,  and  other  systems,  is  under 
consideration. 


CHAPTER  II 
GENERAL  EXAMINATION 

Aspect — Eruptions — Posture — Gait — Shape  and  size  of  the  body 
— The  tongue — Temperature — Respiration — ^The  pulse. 

General  Examination. — ^We  have  now  come  to  the  actual 
examination  of  the  patient,  and  to  the  study  of  the  signs 
of  disease  thereby  disclosed.  A  general  survey  of  the 
condition,  noting  carefully  any  departure  from  a  state 
of  health,  is  to  be  made  ;  then  a  systematic  investiga- 
tion, by  all  the  means  at  our  disposal,  of  the  various 
regions,  systems,  and  organs,  is  to  be  undertaken.  While 
one  is  obliged  to  examine  with  more  minuteness  that 
organ  which  is  obviously  abnormal,  as  in  many  cases  the 
history  and  general  examination  discloses,  it  is  none  the 
less  necessary  to  investigate  all  the  organs  possible,  so 
that  no  obscure  defect  may  be  overlooked. 

In  examining  a  case  we  must  make  use  of  our  best 
powers  of  observation,  utilizing  and  educating  our 
different  senses,  and  availing  ourselves  of  any  clinical 
apparatus  which  is  found  suitable,  supplementing  these, 
where  necessary,  with  more  specialized  laboratory 
methods. 

In  the  general  examination  of  the  individual,  observe 
and  record  any  departure  from  what  you  believe  to  be 
healthy  in  colour,  aspect,  posture,  gait,  shape,  and  con- 
dition of  nutrition  ;  the  state  of  the  teeth  ajid  mouth  ; 

i5 


i6  SYSTEMATIC  CASE-TAKING 

all  obvious  disorders  of  movement,  speech,  manner,  or 
intelligence.  Any  general  evidence  of  departure  from 
health  should  be  here  observed,  so  the  state  of  the 
tongue,  the  temperature,  the  frequency  and  character 
of  the  respirations,  and  the  quality  of  the  pulse,  may 
with  advantage  be  investigated  at  this  early  stage  of 
the  examination. 

The  Aspect  of  the  patient  may  convey  some  informa- 
tion as  to  his  health.  Emaciation  or  the  contrary  con- 
dition of  obesity  may  indicate  merely  personal  habit, 
or  may  be  signs  of  disturbed  metabolism  ;  a  pale  or  a 
florid  complexion  may  be  characteristic  of  the  individual, 
or  may  equally  point  to  some  departure  from  health. 
The  important  point  is  to  ascertain,  if  possible,  whether 
there  has  been  any  changein  these  conditions  since  the 
onset  of  the  malady.  The  expression  of  the  patient's 
face  in  some  instances  is  of  help,  (i)  A  dull,  apathetic 
aspect,  with  a  flushed,  heavy  appearance,  raised  tem- 
perature, and  in  severe  cases  delirium,  dry  tongue,  and 
sordes  on  lips  and  gums,  is  found  in  typhoid  fever  and 
the  so-called  typhoid  state  from  any  cause  ;  a  dull, 
apathetic  expression,  without  accompanying  signs  of 
serious  illness,  is  seen  in  paralysis  agitans  [Parkinson' s 
mask),  in  myxoedema,  and  in  children  suffering  from 
naso-pharyngeal  obstruction.  (2)  An  alert,  active  aspect 
is  characteristic  of  most  fevers,  where  the  illness  has  not 
reached  the  state  of  prostration  referred  to  above,  as  in 
pneumonia,  phthisis,  the  early  stage  of  typhoid  fever, 
etc.  (3)  An  anxious  expression  is  seen  in  many  acute 
inflammatory  states,  particularly  in  those  of  the  ab- 
dominal organs,  and  in  difficulty  of  respiration.  (4)  The 
nervous,  self-conscious  aspect  is  seen  in  hysterical  or 
neurotic  patients.  (5)  Facial  paralysis,  ptosis,  exoph- 
thalmic goitre,  or  mumps,  give  characteristic  aspects. 


GENERAL  EXAMINATION  17 

(6)  The  sunken  eyes,  deeply-lined  face,  sharp  nose,  pale, 
livid,  or  cyanosed  skin,  known  as  the  Hippocratic  facies, 
is  seen  in  moribund  cases,  and  in  serious,  but  not  neces- 
sarily fatal,  diseases  of  the  abdominal  organs,  especially 
in  intestinal  obstruction,  peritonitis,  and  cholera. 

More  definite  changes  of  the  skin  are  to  be  noted. 
Thus  a  yellow  colour  of  the  skin,  if  accompanied  by  a 
similar  tinge  in  the  conjunctiva  and  the  presence  of  bile 
in  the  urine,  indicates  jaundice,  caused  by  the  presence 
of  bile-pigment  in  the  blood.  A  yellowish  colour,  with- 
out, however,  the  conjunctival  tinge,  may  be  found  in 
profound  anaemias,  and  especially  in  pernicious  anaemia. 
A  greenish-yellow  is  seen  in  the  skin  of  young  women 
suffering  from  chlorosis,  and  the  pallor  of  malignant 
disease  has  often  a  muddy  yellowish  shade.  The  skin 
may  be  a  shade  of  blue,  ranging  from  leaden  white  to 
purple  {cyanosis),  due  to  imperfect  oxidation  of  the 
blood,  as  seen  in  respiratory  and  circulatory  disorders. 
Vasomotor  changes  (the  cyanosis  of  paralyzed  limbs,  of 
cold,  of  hysteria  and  Raynaud's  disease),  congenital 
heart  disease,  pressure  of  tumours  interrupting  venous 
return,  may  cause  localized  cyanosis.  Abnormal  pig- 
mentation of  the  skin  is  a  common  disorder.  It  is  seen 
in  jpregnancy  (patches  on  the  face,  chloasma  uterinum, 
and  darkening  of  nipples  and  linea  alba) ;  from  irritation 
of  the  skin  (blisters,  dirt,  vermin) ;  in  Addison's  disease, 
a  bronzing  of  skin  (especially  in  the  regions  where  pig- 
ment is  normally  deposited)  and  of  mucous  membranes. 
A  somewhat  similar  bronze  colour  may  occur  in  Hodg- 
kin's  disease,  arsenic-poisoning,  cirrhosis  of  the  liver, 
diabetes,  and  phthisis.  Melanotic  sarcoma  causes  a  grey 
or  black  discoloration  ;  a  bluish  or  grey  colour  results 
from  prolonged  administration  of  silver  salts  ;  syphilitic 
skin  affections  and  ulcerations  are  apt  to  be  pigmented 


i8  SYSTEMATIC  CASE-TAKING 

to  a  brownish  shade  ;  naevi,  warts,  and  other  skin  affec- 
tions, may  show  considerable  deposits  of  pigment. 

Eruptions. — An  immense  variety  of  skin  eruptions 
may  be  observed.  In  many  cases  these  are  evidence  of 
a  local  disease  of  the  skin,  while  in  others  they  may 
indicate  an  affection  of  Qther  organs  or  some  toxic  con- 
dition of  the  blood.  No  useful  description  of  diseases  of 
the  skin  can  be  attempted  here,  and  the  only  skin  erup- 
tions to  be  referred  to  are  those  which  assist  in  the  diag- 
nosis of  general  medical  affections.  The  following  types 
of  eruption  may  be  noticed  :  Erythema,  roseola,  macules, 
papules,  vesicles,  pustules,  haemorrhage,  wheals,  squamae, 
dermatitis. 

I.  Erythema,  red  discoloration,  usually  in  large  patches 
or  areas.  It  is  seen  in  the  following  :  Scarlatina,  appears 
about  the  second  day  of  the  disease  on  chest  or  abdomen, 
neck  or  face.  Rotheln  (German  measles),  red  spots  ap- 
pearing on  the  first  or  second  day  of  illness  on  the  face ; 
on  the  body  the  spots  join  to  form  red  areas,  while 
on  the  face  they  often  remain  discrete.  Smallpox  and 
tjphoid  fever  often  show  a  preliminary  erythema  before 
the  characteristic  rash  appears.  Erysipelas,  a  bright 
red  rash  with  sharply-defined  edge,  appears  within 
twenty-four  hours  after  the  onset  of  the  illness.  Septic 
poisoning  may  cause  an  erythematous  spotted  or  patchy 
rash  ;  a  similar  eruption  may  occur  as  a  result  of  intes- 
tinal disorders,  and  occasionally  after  a  soap-and-water 
enema.  Infants  the  subjects  of  inherited  syphilis  often 
present  a  red  rash  on  the  buttocks,  while  acquired 
syphilis  has  an  erythematous  or  macular  rash  (more 
commonly  the  latter)  on  the  abdomen  and  thorax, 
rarely  on  the  face  or  hands,  occurring  about  six  weeks 
after  the  appearance  of  the  primary  sore.  Erythema 
nodosum,  raised,  painful,  red  areas,  chiefly  occurring  on 


GENERAL  EXAMINATION  19 

thejront  of  the  leg,  below  the  knee,  and  on  the  extensor 
surface  of  the  arms.  This  is  often  associated  with 
^rheumatism,  which,  however,  may  be  itself  a  cause  of 
various  erythematous  eruptions  on  the  body.  Certain 
drugs  cause  red  rashes— ^.g.,  antipyrine,  sulphonal,  iodine 
and  the  iodides,  iodoform,  bromine  and  the  bromides, 
opium,  belladonna.  Cubebs  and  copaiba  may  cause 
erythema,  but  more  often  macules.  Quinine,  chloral, 
arsenic,  mercury,  salicylate  of  soda,  chlorate  of  potash, 
turpentine,  boric  acid,  benzoic  acid,  strychnine,  may  be 
mentioned  as  chief  among  the  drugs  which  occasionally 
produce  a  red  eruption.  The  injection  of  antidiph- 
theritic  and  other  serums  may  be  followed  by  erythema 
or  a  spotted  rash. 

2.  Roseola  or  Rose-Red  Spots. — The  eruption  of  typhoid 
fever  is  a  good  example.  Small,  round,  slightly  raised 
spots,  disappearing  on  pressure,  commencing  to  appear 
on  abdomen  and  lower  part  of  thorax  about  the  beginning 
of  the  second  week  of  the  disease.  The  secondary  rash 
of  acquired  syphilis  may  be  of  this  description,  but  there 
is  usually  a  brownish  tinge.  In  relapsing  fever  similar 
spots  may  be  seen. 

3.  Papules  diud  Macules — i.e.,  spots  or  blotches,  raised 
somewhat,  and  re3  from  capillary  injection,  usually  dis.- 
appearing  on  pressure.  Seen  in  measles,  usually  on  the 
fourth  day  of  the  illness,  in  clusters,  first  on  the  face, 
spreading  downwards,  and  lasting  four  or  five  days.  The 
eruption  is  also  seen  inside  the  mouth  (on  palate  and 
cheeks).  Inside  the  lips  and  cheeks  whitish  or  bluish 
spots  surrounded  by  a  red  areola  (Koplik's  or  Filatow's 
spots)  may  often  be  found  before  the  cutaneous  rash  is 
well  established.  Rotheln  (German  measles)  and  syphilis, 
see  above  under  Erythema.  In  smallpox,  shotty  papules, 
at  first  on  the  wrists  and  forehead,  appear  about  the 


20  SYSTEMATIC  CASE-TAKING 

third  day  of  the  disease.  The  drugs  mentioned  above 
as  causes  of  erythematous  rashes  will  at  times  cause  also 
papular  and  macular  eruptions.  Injections  of  diph- 
theritic and  other  antitoxic  sera  may  produce  the  same 
effect. 

4.  Vesicles  or  Blisters. — In  smallpox,  the  shotty  papules 
mentioned  above  become  vesicles  about  the  sixth  day 
of  the  disease.  Chicken-pox  shows  papules  on  the 
second  day  of  the  illness.  These  quickly  become 
vesicles,  soon  to  turn  into  pustules.  They  appear  first 
on  the  face  and  trunk,  and  only  occur  on  the  arms 
and  hands  after  they  have  freely  invaded  the  trunk  (in 
which  respect  they  differ  from  the  spots  of  smallpox). 
Herpes  may  arise  in  the  course  of  general  disease.  The 
best  example  is  herpes  facialis,  occurring  near  the  mouth 
or  nostrils  in  pneumonia,  and  also  in  catarrhal  affections 
of  the  respiratory  tract.  It  may  also  be  seen  in  typhoid 
fever  and  in  epidemic  cerebro-spinal  meningitis.  Herpes 
zoster  occurs  as  groups  of  vesicles  along  the  course  of 
one  or  more  cutaneous  nerves.  Sudamina  are  minute 
blisters  occurring  where  sweating  is  profuse — e.g., 
rheuniatism,  phthisis.  As  an  eruption  due  to  drugs, 
vesicles  are  less  common  than  those  already  mentioned. 
They  may  be  due  to  iodides,  bromides,  arsenic,  salol,  or 
copaiba.  All  these  vesicular  eruptions  tend  to  become 
pustular  in  the  course  of  their  development. 

5.  Wheals  (urticarial  eruptions)  most  frequently  arise 
as  a  result  of  disturbance  of  the  digestive  functions  ; 
also  from  septic  absorption  from  the  digestive  tract  or 
other  surface,  serum  injections,  soap-and-water  enemata. 
Many  of  the  drugs  already  mentioned  cause  eruptions 
of  this  character. 

6.  Pustules. — ^The  papular  and  vesicular  eruptions 
often  become  pustular  (chicken-pox,  smallpox,  herpes). 


GENERAL  EXAMINATION  21 

The  pustular  drug  eruptions   are  common  in  iodine, 
bromine,  and  arsenic  poisoning. 

7.  HcBmorrhages. — Small  spots,,  red  or  dark  in  colour, 
which  do  not  disappear  on  pressure  (petechice),  streaks 
of  similar  character  [vibices),  and  larger  patches  of  dis- 
coloration {ecchymoses) ,  result  from  the  escape  of  blood 
from  the  vessels  into  and  under  the  skin.  A  good 
example  is  seen  in  purpura,  with  petechise,  vibices,  and 
ecchymoses  all  over  the  body,  but  usually  best  marked 
on  the  legs.  This  occurs  in  a  variety  of  severe  toxic 
states  of  the  blood — 6.g.,  pyaemia,  septicaemia,  gonorrhoeal 
infection,  ulcerative  endocarditis — or  it  may  be  a  so- 
called  idiopathic  or  primary  disease  (purpura  simplex), 
of  which  a  severe  form  is  purpura  haemorrhagica  or 
morbus  maculosus  of  Werlhof,  in  which  there  is  not 
only  bleeding  into  the  skin,  but  also  in  many  other 
.regions  and  organs.  Purpura  associated  with  articular 
rheumatism  is  known  as  peliosis  rheumatica,  or  Schon- 
lein's  disease.  Signs  of  gastro-intestinal  irritation  may 
be  added  to  this  condition,  chiefly  among  children, 
the  affection  being  then  known  as  Henoch's  purpura. 
Scurvy,  haemophilia,  leukaemia,  and  splenic  anaemia, 
may  be  mentioned  as  conditions  associated  with  cutane- 
ous haemorrhage.  In  typhus  fever  the  eruption  is 
petechial,  occurring  first  over  the  upper  region  of  the 
thorax  and  abdomen  about  the  fifth  day  of  the  disease. 
In  measles  and  smallpox,  when  severe,  the  eruption 
may  show  signs  of  cutaneous  haemorrhage.  The  pus- 
tules of  iodide  or  bromide  eruption  may  be  filled  with 
blood,  or  petechiae  may  occur.  Petechiae  may  also  be 
seen  in  cases  of  antipyrine  and  sulphonal  poisoning. 

8.  Inflammation  of  the  Skin  (dermatitis)  is  more  com- 
monly found  in  local  affections  of  the  skin.  It  may  occur, 
however,  in  gout,  syphilis,  arsenic  and  iodine  poisoning. 


22  SYSTEMATIC  CASE-TAKING 

9.  Desquamation  occurs  as  a  fine  branny  peeling  of 
the  superficial  skin  layers  after  most  cases  of  inflamma- 
tion or  hypersemia  of  the  skin  (measles,  rotheln,  ery- 
sipelas). In  scarlet  fever  the  skin  peels  off  in  larger 
flakes,  especially  where  it  is  thick,  as  on  the  palms  of 
the  hands  and  the  soles  of  the  feet. 

The  Posture  is  often  suggestive.  The  patient  is  unable 
to  lie  down  in  bed,  owing  to  difficulty  in  breathing  [ortho- 
pncea),  as  observed  in  serious  heart  affections,  asthma,  em- 
physema, mediastinal  tumour.  He  lies  on  his  back — in  a 
comfortable  posture  when  he  is  not  seriously  ill  ;  in  an 
uncomfortable  attitude,  slipping  downwards  in  the  bed, 
in  states  of  prostration  ;  with  one  leg  drawn  up  and 
abdominal  muscles  of  that  side  rigid,  in  inflammatory 
affections  of  one  side  of  the  abdomen  ;  with  both  legs 
drawn  up,  the  inflammation  is  more  widely  spread  in  the 
peritoneal  cavity.  He  lies  on  his  face  :  painful  and  non- 
inflammatory abdominal  disorders — e.g.,  renal,  intestinal, 
or  gall-stone  colic.  He  lies  on  his  side  :  he  may  be  in  a 
condition  of  cerebral  irritation,  with  limbs  flexed  at  every 
joint,  resenting  any  attempt  to  move  him — a  condition 
seen  in  irritative  intracranial  lesions — e.g.,  meningitis, 
haemorrhage,  pressure.  On  his  side  with  head  retracted 
suggests  meningitis  ;  lying  on  his  side,  with  obvious 
difficulty  in  breathing,  may  indicate  pleurisy  or  pneu- 
monia of  the  side  upon  which  he  is  lying.  A  rigidity 
of  posture  occurs  in  tetanus  and  strychnia-poisoning. 
The  dorsal  muscles  may  prevail,  causing  an  arching  of 
the  back,  so  that  the  body  may  rest  upon  the  head  and 
heels  [opisthotonos)  ;  a  forward  curve  may  occur  [em- 
prosthotonos)  ;  the  curve  may  be  to  one  side  (pleurostho- 
tonos)  ;  the  trunk  muscles  may  antagonize  each  other, 
so  that  the  body  is  straight  and  rigid  [orthotonos). 

Gait. — The  mode  of  progression  is  to  be  noted,  and 


GENERAL  EXAMINATION  23 

the  following  different  types  of  movement  may  be  dis- 
tinguished :  The  spastic  gait,  characterized  by  stiffness 
in  the  motion,  due  to  exaggerated  muscular  tone,  espe- 
cially of  the  extensor  muscles.     It  occurs  in  affections 
of  the  central  nervous  system  in  which  the  leg  reflexes 
are  intensified  (see  Chapter  IX.  and  Appendix  XL) .     The 
ataxic  gait,  due  to  defective  co-ordination  of  muscular 
"a^lKnT   The  movements  of  the  limb  are  inaccurate  and 
uncertain,  and  particularly  so  if  he  removes  his  eyes  from 
the  ground  at  his  feet — a  condition  best  seen  in  loco- 
motor ataxia.     The  ataxic  gait  of  tabes  may  be  of  a 
stamping  character — when  he  raises  his  limb  with  un- 
necessary force,  bringing  it  down  again  with  a  stamp. 
A  greater  degree  of  muscular  inco-ordination  is  seen  in 
the  reeling  gait  of  cerebellar  disease,  affections  of  the 
middle  ear,  alcoholic  intoxication,  etc.     Pseudo-ataxic  or 
paretic  gait  is  seen  in  cases  of  muscular  weakness,  and 
particularly  in  peripheral  neuritis   affecting  the  legs. 
Here  the  foot  tends  to  hang  ("  dropped  foot  "),  and  the 
knee  is  unduly  raised  in  order  that  the  toe  may  clear 
the  ground  {steppage  gait).     As  a  rule,  some  inco-ordina- 
tion due  to  defective  muscular  sense  is  also  found  in 
these  cases.     A  festinating  gait  is  occasionally  seen  in 
paralysis  agitans,  where  the  patient  has  a  tendency  to 
fall  forward,  and  in  order  to  preserve  his  balance  he 
gradually  increases  the  speed  of  his  progression.     A 
waddling,   rolling  gait  is  seen  in  cases   of   abdominal 
tumours,  ascites,  pregnancy,  obesity,  and  in  pseudo- 
hypertrophic   paralysis.     Every    variety    of    lameness 
results  from  lesions  of  one  or  both  legs. 

The  Shape  and  Size  of  the  Body.— A  general  enlarge- 
ment may  be  dropsy  (anasarca),  but  is  more  commonly 
excessive  fat  deposit.  The  thorax  may  be  generally 
enlarged  in  emphysema,  or  present  local  enlargement 


24  SYSTEMATIC  CASE-TAKING 

from  tumour  or  aneurism.  Abdominal  swelling  may  be 
due  to  obesity,  tumour,  pregnancy,  ascites,  flatulent  dis- 
tension. Enlargement  of  the  head  is  seen  in  rickets, 
hydrocephalus,  and  in  acromegaly  (head  and  face).  The 
limbs  are  enlarged  in  oedema  and  in  surgical  conditions 
(tumours,  inflammations) .  Medical  diseases  of  the  limbs 
are  rheumatism,  erythema  nodosum,  osteo-arthritis, 
arthropathies  of  trophic  nervous  origin,  and  pseudo- 
hypertrophic muscular  paralysis. 

Diminution  in  size  due  to  wasting  disease  may  be 
mere  atrophy  of  disuse ;  it  may  be  the  emaciation  of 
imperfect  nutrition,  or  of  one  of  the  rarer  muscular 
dystrophies,  or  it  may  be  the  result  of  disease  of  certain 
regions  of  the  nervous  system. 

Disorders  of  movement,  speech,  and  intelligence,  being 
in  most  cases  indications  of  disturbances  of  the  nervous 
system,  are  at  this  stage  to  be  only  generally  surveyed, 
their  detailed  examination  being  taken  again  when  the 
nervous  system  is  reached  (Chapter  IX.). 

The  Tongue  may  now  be  examined  as  an  index  to 
disease  in  the  body  generally.  Observe  the  colour,  coat- 
ing (if  any),  tone,  size,  and  movements,  lis  colour  is 
pale  in  ansemic  conditions  ;  red  in  tubercular  disease, 
in  the  early  stage  of  scarlet  fever,  in  the  typhoid  state 
(when  it  is  also  dry)  ;  bluish  in  cyanosis  ;  dark  in  Addi- 
son's disease  ;  yellow  in  jaundice  (especially  on  its  under- 
surface).  A  coating  of  thin  whitish  "  fur  "  may  occur 
in  health,  in  digestive  disorders,  and  in  most  feverish 
states.  If  thick,  yellow,  or  brown,  it  may  result  from 
the  same,  but  more  severe,  causes,  or  from  the  abuse 
of  alcohol  or  tobacco.  In  typhoid  fever  the  coating  is 
often  thick  over  the  dorsum,  but  thin  or  absent  on  the 
edges  and  tip  and  anterior  part  of  the  middle  line.  A 
dry,  brown,  or  dark  fur  indicates  prostration  and  fever, 


GENERAL  EXAMINATION  25 

and  is  seen  in  the  "  typhoid  state  "  from  any  severe 
disease.  A  whitish  coating,  through  which  the  bright 
red  papillae  project  (the  strawberry  tongue),  occurs  in 
fevers,  and  especially  in  the  early  stages  of  scarlet  fever. 
Inflammations  of  the  mouth  (carious  teeth,  tonsillitis, 
etc.)  cause  a  thick  coating.  The  fur  may  be  coloured 
by  drugs  (black  by  bismuth,  iron,  or  charcoal ;  white  by 
carbolic  acid)  or  by  food.  A  defective  tone  or  flabby 
state  of  the  tongue,  showing  indented  teeth-marks,  indi- 
cates debility  and  anaemia.  Increase  in  size  of  the 
tongue  is  usually  due  to  inflammation  (glossitis)  ;  it  is 
seen  also  in  cretinism  and  myxoedema.  Decrease  in  size 
is  found  in  serious  disease  with  prostration — e.g.,  typhus 
fever,  advanced  typhoid  fever,  profuse  haemorrhage, 
cholera.  Lesions  of  the  hypoglossal  nerves  or  of  their 
nuclei  cause  marked  atrophy  of  the  tongue.  Tremor  of 
the  tongue  occurs  in  healthy  persons  of  a  neurotic  tem- 
perament ;  also  in  many  disorders — e.g.,  acute  and 
chronic  alcoholism,  prostration,'multiple  sclerosis,  general 
paralysis  of  the  insane,  bulbar  paralysis.  Paralysis  of 
the  tongue  is  shown  by  inability  to  protrude  the  organ 
properly.  If  unilateral,  the  tongue  is  deviated  toward 
the  affected  side  when  protruded  ;  if  the  lesion  causing 
the  paralysis  be  nuclear  or  infranuclear,  the  tongue  will 
be  atrophied  and  wrinkled  ;  if,  on  the  other  hand,  the 
lesion  be  above  the  hypoglossal  nucleus,  it  is  usually 
one-sided,  and  there  is  no  marked  atrophy  of  the  affected 
part.  A  bilateral  atrophic  lingual  paralysis  occurs  in 
bulbar  paralysis  ;  a  similar  condition  without  atrophy  is 
produced  by  a  two-sided  lesion  above  the  nuclei — a  rare 
condition  termed  pseudo-bulbar  paralysis. 

Tumours,  ulcers,  and  other  lesions  of  the  tongue,  are 
usually  local  affections,  without  general  diagnostic  in- 
terest.    As  exceptions  to  this  may  be  mentioned  the 


26  SYSTEMATIC  CASE-TAKING 

lacerations  of  the  tongue  by  the  teeth  clenched  in  an 
epileptic  fit,  and  the  small  ulcer  of  the  frenum  caused 
by  the  lower  incisors  in  whooping-cough. 

Temperature. — ^The  temperature  of  the  body  is  most 
suitably  taken  in  the  mouth  ;  it  is  more  accurate,  but 
less  convenient,  when  taken  in  the  rectum  ;  the  least 
accurate,  but  most  convenient,  method  is  the  axilla, 
where  the  temperature  may  be  i°  lower  than  in  the 
mouth.  In  the  case  of  children  the  groin  is  a  very 
suitable  place  to  make  the  observation.  A  temperature 
between  98°  and  99°  F.  may  be  regarded  as  normal. 
Acute  inflammatory  affections  are  almost  always  accom- 
panied by  a  rise  of  temperature  above  normal  (pyrexia) . 
The  range  of  the  temperature,  its  mode  of  onset,  dura- 
tion, and  defervescence,  are  often  characteristic  of  the 
disease  of  which  it  is  an  important  sign. 

1.  The  invasion  or  onset  of  the  fever  may  be  abrupt, 
in  which  case  it  is  often  accompanied  or  preceded  by  a 
rigor,  or  in  children  sometimes  by  a  convulsion.  Sudden 
onset  occurs  in  croupous  pneumonia,  scarlet  fever,  ton- 
sillitis, influenza,  erysipelas,  digestive  disorders  in  chil- 
dren. A  gradual  onset  is  commoner,  and  is  seen  in  most 
of  the  acute  feverish  conditions — e.g.,  typhoid  fever, 
measles,  bronchitis,  broncho-pneumonia,  rheumatism,  etc . 

2.  The  height  of  the  fever,  ov  fastigium,  may  be  continued 
without  much  fall  till  the  end  of  the  feverish  period  is 
near,  as  in  pneumonia,  typhoid  fef er.  A  remittent  tem- 
perature has  a  daily  fall,  approaching,  but  not  reaching, 
normal.  Examples:  phthisis,  suppuration,  pyelitis,  septic 
infection,  typhoid  fever  in  the  third  week.  Intermittent 
fever  has  periods  free  from  fever.  It  may  occur  in 
hectic  conditions  and  suppuration,  in  sepsis,  and  typically 
in  malaria.  If  the  intermission  lasts  more  than  a  day, 
it  is  termed  relapsing  fever.     Influenza,  typhoid  fever, 


GENERAL  EXAMINATION  27 

relapsing  fever,  and  malaria,  may  show  this  type  of 
pyrexia. 

3.  The  termination  of  the  high  temperature  may  be 
sudden,  falling  to,  or  nearly  to,  normal  in  about  twenty- 
four  hours.  This  is  known  as  a  crisis,  and  may  be  seen 
in  croupous  pneumonia,  measles,  chicken-pox,  tonsil- 
litis, relapsing  fever,  malaria.  A  sudden  fall  of  the 
temperature  below  normal  may  be  an  unfavourable  sign 
(see  below).  A  defervescence  by  lysis  or  gradual  fall  of 
the  temperature  is  the  termination  of  most  fevers — e.g., 
rheumatism,  typhoid  fever,  broncho-pneumonia,  scarlet 
fever,  pleurisy,  septic  infections.  A  termination  by  lysis 
in  diseases  which  usually  end  by  crisis  often  indicates 
the  supervention  of  some  complication. 

Hyperpyrexia,  or  a  temperature  above  106°  F.,  may 
occur  in  the  course  of  some  of  the  fevers,  especially  in 
acute  rheumatism,  typhoid  fever,  malaria,  and  sun- 
stroke. It  is  commonly  seen  as  the  termination  in  fatal 
cases  of  injuries  of  the  brain  and  cervical  portion  of  the 
spinal  cord,  in  typhoid  fever,  scarlet  fever,  tetanus,  etc. 

Subnormal  Temperature. — In  certain  chronic  diseases 
the  temperature  is  commonly  below  98°  F.  A  sudden 
fall  from  fever  height  to  below  normal  is  one  of  the  signs 
of  collapse.  The  pulse  is  more  frequent,  becomes  small, 
of  low  tension,  and  often  irregular  ;  there  may  be  diffi- 
culty in  breathing,  with  sighing,  frequent,  or  slow  respira- 
tions. In  all  these  respects  the  sudden  fall  of  tempera- 
ture differs  from  that  of  a  favourable  crisis.  Collapse 
occurs  in  a  variety  of  serious  conditions,  of  which  may 
be  mentioned  heart  failure  in  acute  diseases,  such  as 
pneumonia  or  scarlet  fever ;  bleeding  from  typhoid, 
gastric,  or  duodenal  ulcers,  from  an  extra-uterine  preg- 
nancy, or  from  the  lungs  ;  perforation  of  viscera,  as  in 
typhoid  fever,  gastric  or  duodenal  ulcer. 


28  SYSTEMATIC  CASE-TAKING 

Respiration. — ^The  frequency  of  this  act  is  to  be  noted, 
and  any  difficulty  experienced  by  the  patient  may  be 
here  recorded.  The  more  detailed  examination  of  the 
respiration  may  be  deferred  till  the  special  examination 
of  the  respiratory  system  is  undertaken  (see  Chapter  IV.). 

The  Pulse. — The  pulsation  of  the  radial  artery  is  to 
be  examined,  and  information  sought  on  the  following 
points :  (i)  The  tension  ;  (2)  the  condition  of  the  arterial 
walls ;  (3)  the  frequency  and  rhythm ;  (4)  the  volume  ; 
(5)  the  duration  of  the  pulse. 

Methods  of  Examining  the  Pulse. — By  inspection  one 
can  at  times  observe  the  pulse.  Pulsations  of  more 
than  ordinary  amplitude  may  be  visible  in  the  radial 
artery,  as  commonly  occurs  in  aortic  incompetence. 
Here  the  vessel  is  often  tortuous,  and  may  be  seen  to 
move  with  each  beat  [movable  or  locomotive  pulse). 
Digital  examination  is  best  accomplished  by  placing 
three  fingers  on  the  artery  at  the  wrist,  the  distal  and 
proximal  fingers  controlling  the  pulsations,  and  the 
middle  finger  observing  the  character  of  the  pulse.  By 
rolling  the  vessel  under  the  fingers  the  condition  of  its 
walls  may  be  ascertained. 

The  sphygmograph  gives  a  graphic  record  of  the  beats. 
The  tracing  made  by  the  instrument  represents  the  wave 
which  has  reached  the  radial  artery  one-tenth  of  a  second 
after  it  was  created  by  the  contraction  of  the  left  ven- 
tricle. The  up-stroke  of  the  lever  is  due  to  the  primary 
or  percussion  wave.  Owing  to  the  momentum  acquired 
by  the  lever,  it  rises  too  high,  and  in  its  fall  again  it 
meets  the  termination  of  the  wave,  which  forms  a  little 
elevation,  generally  known  as  the  secondary,  tidal,  or 
predicrotic  wave.  This  is  followed  by  an  elevation  of  the 
lever  causing  the  dicrotic  wave,  which  immediately  fol- 
lows on  the  closure  of  the  semilunar  cusps,  and  is  the 


GENERAL  EXAMINATION       .  29 

result  of  recoil  from  the  closed  aortic  valve.  The  de- 
pression immediately  preceding  the  dicrotic  wave  is 
termed  the  dicrotic  or  aortic  notch.  Other  small  secon- 
dary waves  may  be  seen  in  the  down-stroke  of  the 
tracing,  the  significance  of  which  is  uncertain.  In 
disease  of  the  heart,  kidneys,  and  other  organs,  one 
finds  considerable  departures  from  the  character  of 
pulse-tracing  just  described. 

The  sphygmomanometer  is  an  instrument  devised  to 
determine,  in  terms  of  the  height  of  a  column  of  mer- 
cury, the  degree  of  tension  of  the  systemic  arteries. 
There  are  now  many  varieties  of  instrument  for  this 
purpose.  That  of  Riva  Rocci,  modified  by  Martin, 
Oliver,  Hill,  and  others,  is  probably  the  best  for  clinical 
use.  It  consists  of  a  rubber  sleeve,  about  5  inches  wide, 
forming  an  air-tight  bag,  and  covered  by  an  inextensible 
leather  or  canvas  band.  The  rubber  bag  is  connected 
with  an  air-pump  and  also  with  a  manometer.  The  bag 
is  fastened  round  the  patient's  arm  just  above  the  elbow, 
air  is  pumped  in  until  the  pressure  is  sufficient  to  obliter- 
ate the  pulsation  at  the  radial,  and  the  manometer  shows 
the  pressure  attained  in  millimetres  of  mercury  ;  or  an 
excessive  amount  of  pressure  (more  than  enough  to 
obliterate  the  pulsations)  having  been  introduced  into 
the  bag,  the  air  is  allowed  to  escape  slowly,  and  as  soon 
as  the  pulsations  are  felt  to  return  in  the  radial,  the 
manometer  reading  is  recorded.  This  is  taken  as  the 
systolic  tension,  and  normally  the  mercurial  column 
reaches  the  height  of  from  100  to  140  millimetres. 
During  all  these  procedures  the  mercury  in  the  mano- 
meter is  seen  to  oscillate  with  each  pulsation.  At  a 
certain  point  of  pressure,  lower  than  that  taken  to 
indicate  the  systolic  tension,  the  pulsating  excursions 
of  the  mercury  are  at  their  maximum  amplitude.     This 


30  SYSTEMATIC  CASE-TAKING 

point,  which  is  difficult  to  determine,  is  to  be  noted  as 
the  diastolic  tension. 

Other  forms  of  sphygmomanometer  compress  the  radial 
artery  just  above  the  wrist  (von  Basch's)  or  measure  the 
pressure  which  is  sufficient  to  prevent  the  blood  return- 
ing to  a  finger  from  which  the  blood  had  been  previously 
pressed  (Gartner's). 

I.  Tension  of  the  arteries  may  be  investigated  by  any 
of  the  methods  above  mentioned  ;  by  education  the 
fingers  can  help  us  to  decide  if  the  pulsations  are  more 
or  less  easily  abolished  by  pressure  than  normal.  In 
cases  of  high  tension  the  sphygmograph  forms  a  charac- 
teristic curve.  The  up-stroke  is  somewhat  sloping ;  the 
line  is  sustained  at  its  height,  forming  a  blunt  curve,  the 
apex  of  which  may  be  a  plateau,  or  may  even  rise  higher 
than  the  percussion  wave.  When  the  latter  condition 
is  found,  the  pulse  is  termed  anacrotic.  The  dicrotic 
wave  is  indefinite  or  imperceptible,  while  the  secondary 
waves  are  increased  in  amplitude  and  number.  A  low- 
tension  tracing  shows  a  vertical  up-stroke,  a  sharp 
summit  wave,  and  a  well-marked  dicrotic  wave,  while 
the  tidal  or  elasticity  waves  are  ill-marked  or  absent. 
In  some  cases  of  low  tension — e.g.,  fevers — the  dicrotic 
wave  may  be  easily  felt  by  the  examining  finger — the 
so-called  dicrotic  pulse. 

The  degree  of  tension  depends  on — (i)  the  strength  of 
the  ventricular  contractions ;  (2)  the  volume  of  blood 
in  the  arteries  ;  (3)  the  peripheral  resistance  ;  and  (4)  the 
elasticity  of  the  arterial  walls.  The  removal  of  blood 
from  the  arteries  lowers  the  pressure  if  the  other  condi- 
tions are  undisturbed.  In  haemorrhage,  however,  the 
pressure  is  usually  maintained  up  to  a  certain  point  by 
contraction  of  the  peripheral  vessels,  the  resistance  being 
thus  increased.    The  increased  cardiac  activity  resulting 


GENERAL  EXAMINATION  31 

from  alcohol  is  largely  neutralized  by  relaxation  of  the 
peripheral  vessels.  In  shock  and  collapse  there  is  vaso- 
motor paralysis,  which  lowers  the  peripheral  resistance, 
together  with  transference  of  blood  from  the  arteries  to 
the  vessels  of  the  splanchnic  area  ;  hence  a  marked  and 
dangerous  low  tension  results.  In  fevers  the  diminished 
peripheral  resistance  lowers  the  tension,  in  spite  of  the 
frequent  and  usually  excited  cardiac  action.  Dimin- 
ished elasticity  occurs  in  arterio-sclerosis,  with  a  conse- 
quent rise  of  arterial  pressure.  In  kidney  affections, 
and  especially  in  the  small  red  kidney,  the  increased 
peripheral  resistance  resulting  from  contracted,  and 
sometimes  from  sclerotic,  arteries,  as  well  as  cardiac 
hypertrophy,  causes  in  most  cases  an  increase  in  the 
arterial  tension.  Cardiac  disease  commonly  causes  low 
tension;  but  when  arterio-sclerosis  is  present,  a  fairly 
high  tension  may  be  maintained.  In  the  case  of  aortic 
incompetence  the  powerfully  contracting  left  ventricle 
causes  a  momentary  systolic  high  tension,  followed  by 
mean  and  diastolic  low  tension,  the  so-called  collapsing, 
water-hammer,  or  Corrigan's  pulse  {pulsus  celer).  In 
mitral  obstruction  or  regurgitation  the  amount  of  blood 
which  reaches  the  arteries  with  each  beat  is  diminished, 
and  the  pulse  is,  in  consequence,  of  low  tension. 

2.  The  Condition  of  the  Walls  oj  the  Artery. — If  the 
walls  of  the  vessel  can  be  recognized  by  the  finger  while 
the  pulsations  are  abolished  by  compression  higher  up 
the  arm,  then  we  may  conclude  that  the  vessel  walls  are 
unduly  thickened.  In  old  age  this  may  be  looked  on  as 
the  normal  state — senile  degeneration.  In  younger  sub- 
jects it  is  usually  an  indication  of  arterio-sclerosis,  often 
associated  with  chronic  sclerotic  and  degenerative  changes 
in  the  kidneys.  Another  cause  of  thickened  arteries  is 
syphilitic  arteritis,  occurring,  as  a  rule,  in  young  subjects. 


32  SYSTEMATIC  CASE-TAKING 

3.  The  Frequency  and  Rhythm  of  the  Pulse. — Consider- 
able differences  in  the  rate  of  the  heart-beat  occur  in 
healthy  individuals,  but  in  most  cases  the  adult  fre- 
quency may  be  stated  as  70  to  75  per  minute.  In  in- 
fancy the  rate  commences  at  about  120  to  140,  de- 
creasing gradually  till  adult  age  is  reached.  In  old  age 
the  frequency  again  increases  somewhat.  Emotional 
and  muscular  activity,  even  in  slight  degree,  increase  the 
pulse-rate.  It  is  a  little  quicker  on  the  average  in 
women  than  in  men,  in  short  people  than  in  tall,  during 
action  than  in  rest  of  the  digestive  organs. 

A  rapid  pulse  is  seen  in  fevers  ;  the  increased  pulse- 
rate  is  usually  in  proportion  to  the  rise  in  temperature. 
Some  exceptions  to  this  rule  may  be  noted.  In  scarla- 
tina the  increased  frequency  of  the  pulse  is  a  marked 
feature,  while  the  rise  in  temperature  is  only  moderate  ; 
in  typhoid  fever  it  is  the  reverse  which  obtains.  A  slow 
pulse  with  raised  temperature  is  seen  in  intracranial 
disease  in  which  there  is  inflammation  combined  with 
intracranial  pressure,  as  is  often  the  case  in  tuberculous 
meningitis  and  cerebral  abscess  ;  the  opposite  condition 
of  low  temperature  with  rapid  pulse  is  found  in  collapse. 

A  frequent  pulse  without  a  corresponding  rise  of  tem- 
perature in  cases  of  fever  is  of  more  serious  import  than 
a  moderate  pulse-rate  with  a  high  temperature. 

The  ratio  of  the  pulse-rate  to  that  of  respiration 
remains  in  most  cases  fairly  constant  at  about  4  to  i. 
The  most  notable  exception  to  this  is  found  in  pneumonia, 
where  the  pulse-respiration  ratio  may  be  2  to  i,  or  even 
nearly  equal. 

A  rapid  pulse  without  fever  occurs  in  exophthalmic 
goitre,  endocarditis  and  its  resulting  valvular  disease, 
pericarditis,  chlorosis  and  other  anaemias,  hysteria, 
general  debility,  abuse  of  tobacco,  alcohol,  and  tea. 


GENERAL  EXAMINATION  33 

Certain  drugs,  of  which  atropine  is  the  best  example, 
quicken  the  pulse. 

Attacks  of  frequent  pulse-beats,  lasting  perhaps  an 
hour  or  more,  and  occurring  at  irregular  intervals  and 
often  on  slight  provocation,  may  go  on  for  long  periods, 
often  for  years.  The  condition  is  known  as  paroxysmal 
tachycardia.  By  some  writers  the  term  "  tachycardia  " 
is  used  for  all  cases  in  which  the  pulse-rate  exceeds  120 
per  minute,  while  others  restrict  the  use  of  the  word  to 
those  paroxysmal  and  recurring  cases  just  mentioned. 

The  opposite  condition,  in  which  the  pulse  is  unduly 
infrequent  {bradycardia) ,  occurs  in  cachectic  states  ;  in 
high  arterial  tension  ;  in  aortic  stenosis  (unlike  most 
other  valvular  diseases)  ;  in  conditions  producing  intra- 
cranial pressure,  especially  when  the  latter  has  rapidly 
developed.  In  other  affections  of  the  nervous  system 
bradycardia  is  at  times  observed — e.g.,  melancholia, 
mania,  epilepsy,  sunstroke ;  in  myxoedema ;  certain 
poisons  in  the  blood — e.g.,  digitalis,  opium,  carbon  mon- 
oxide, lead,  bile,  urea. 

Disturbance  of  the  rhythmical  recurrence  of  the  heart- 
beat has  two  sources  of  origin  :  disturbing  influences  act- 
ing upon  the  nervous  connections  between  the  heart  and 
the  central  nervous  system — that  is,  the  vagus  and  the 
sympathetic  nerves ;  and  some  interference  affecting 
injuriously  those  qualities  which  healthy  heart  muscle 
must  possess  in  order  to  insure  regularly  recurring  con- 
tractions— those  qualities  being  rhythmicity,  excita- 
bility, contractility,  conductivity,  and  tonicity. 

In  most  cases  the  irregularity  does  not  follow  any 
definite  type  ;  some,  however,  are  only  partially  irregu- 
lar. A  common  form  of  the  latter  is  the  intermittent 
pulse  {pulsus  intercidens).  Here  a  beat  is  apparently 
missed  at  intervals  more  or  less  irregular.    Whilst  the 

3 


34  SYSTEMATIC  CASE-TAKING 

radial  pulse  is  being  digitally  examined,  the  stethoscope 
is  placed  over  the  heart ;  the  beat  immediately  pre- 
ceding the  missed  beat  in  the  radial  is  noticed  by 
auscultation  to  be  apparently  doubled,  or  the  doubling 
may  be  at  times  observed  by  the  fingers  on  the  radial 
artery.  This  doubled  beat  is  due  to  the  occurrence  of 
a  premature  or  extra  systole  of  the  ventricles  at  a  moment 
when  the  excitability  of  the  muscle  has  not  reached  its 
most  effective  period — that  is,  it  occurred  too  early  in 
the  diastole — and  hence  the  resulting  contraction  was 
so  weak  that  the  pulse-wave  barely  reached  the  wrist. 
This  irregularity  is  often  produced  in  hearts  which  have 
no  other  signs  of  disease,  and  may  be  transient  and 
without  pathological  significance  ;  on  the  other  hand,  it 
is  commonly  a  sign  of  failing  compensation. 

At  times  one  observes  two  beats  followed  by  a  pause 
(the  bigeminal  pulse),  or  three  beats  similarly  grouped 
(the  trigeminal  pulse).  This  is  probably  the  result  of 
extra  systoles  occurring  at  regular  intervals. 

4.  The  Volume  of  ihe  Pulse. — ^The  pulsations  may  be 
of  small  amplitude — small  pulse  (pulsus  parvus) — as  in 
high  tension,  which  interferes  with  the  expansile  move- 
ments of  the  vessel  wall.  In  low  tension  the  volume 
may  also  be  small,  as  in  heart  failure  from  any  cause. 
With  a  hjrpertrophied  left  ventricle  and  ef&cient  mitral 
valve  there  may  still  be  a  small  pulse  when  an  obstruc- 
tion exists  between  the  ventricle  and  the  radial  artery, 
as  in  the  case  of  thoracic  or  brachial  aneurism  or  stenosed 
aortic  orifice. 

The  large  pulse  (pulsus  magnus)  is  found  in  those  con- 
ditions which  favour  the  transmission  of  a  large  wave 
from  the  heart  to  the  periphery — viz.,  a  strongly  acting 
heart,  low  arterial  tension,  elasticity  of  the  arterial  walls, 
and  an  ample  supply  of  blood  passing  without  obstruc- 


GENERAL  EXAMINATION  35 

tion  to  the  periphery.  Should  the  heart  muscle  weaken, 
the  pulse  will  then  become  small  and  thready,  in  spite 
of  the  lowered  tension.  A  markedly  large  pulse  {pulsus 
celer)  is  found  in  aortic  incompetence,  as  mentioned 
above. 

When  a  strong  and  a  weak  beat  alternate,  the  pulse 
is  known  as  pulsus  alternans.  If  the  intervals  between 
the  beats  be  equal,  this  form  of  arrhythmia  often  indi- 
cates serious  impairment  of  the  contractile  power  of  the 
heart  muscle  ;  if  the  smaller  beat  be  followed  by  a  longer 
interval  than  that  which  precedes  it,  the  rhythm  is 
probably  not  pulsus  alternans,  but  pulsus  bigeminus, 
the  result  of  extra  systoles.  Diminution  or  even  dis- 
appearance of  the  pulse  during  the  act  of  inspiration 
{pulsus  paradoxus)  may  be  observed  in  some  cases  of 
adherent  pericardium.  Occasionally  this  rhythm  has 
been  noticed  in  cases  of  pleurisy,  pneumonia,  obstruc- 
tion of  the  air-passages,  and  valvular  heart  disease. 

5.  The  Duration  of  the  Pulse. — ^The  pulse-wave  may 
be  felt  as  if  quickly  filled  and  as  quickly  emptied  in  the 
pulsus  celer  referred  to  above,  while  the  slow  pulse 
{pulsus  tardus)  consists  of  a  wave  of  longer  duration. 


CHAPTER  III 
THE   THORAX 

Topography — Methods  of  examination — Shape  of  the  chest. 

Topography. — For  facility  in  recording  the  result  of 
examinations,  the  surface  of  the  chest  is  mapped  out 
into  regions  by  means  of  natural  landmarks  and  by 
the  following  artificial  lines,  all  of  which  run  verti- 
cally :    (i)  Midsternal  line,  the  median  line  in  front ; 

(2)  side-sternal  line,  over  each  border  of  the  sternum  ; 

(3)  mammillary  or  nipple  line,  a  line  through  the  nipple  or, 
in  the  case  of  females,  through  the  middle  of  the  clavicle  ; 

(4)  parasternal    line,    midway    between    (2)   and    (3) ; 

(5)  anterior  axillary  line,  through  the  spot  where  the 
anterior  axillary  fold  joins  the  thorax,  the  arm  being 
held  out  horizontally ;  (6)  posterior  axillary  line,  corre- 
spondingly through  the  posterior  axillary  fold  ;  (7)  mid- 
axillary  line,  midway  between  (5)  and  (6)  ;  (8)  scapular 
line,  through  the  inferior  angle  of  the  scapula  ;  (9)  spinal 
line,  the  median  line  behind. 

The  natural  landmarks  are  the  ribs,  clavicles,  nipples, 
spines  of  the  scapulae,  and  vertebral  spines,  of  which 
the  seventh  cervical  is  usually  easily  recognized.  The 
junction  of  the  upper  and  middle  portions  of  the  sternum 
(angle  of  Ludwig)  marks  the  level  of  the  second  costal 
cartilages. 

36 


Topography    of    the    Thorax    and    Abdomen    (from 
"  Dictionary  of  Medical  Diagnosis  "). 

A,  midsternal  line;  B,  side-sternal  line;  C,  parasternal  line; 
D,  nipple  line  ;  E,  anterior  axillary  line  ;  F,  right  hypo- 
chondriac region  ;  G,  epigastric  region  ;  H,  right  lumbar 
region  ;  /,  umbilical  region  ;  /,  right  iliac  region  ;  K,  hypo- 
gastric region  ;  T,  Traube's  semilunar  space  ;  ii,  Hi,  iv,  v, 
on  the  left  ribs  of  the  same  numbers.  The  shaded  areas  are 
the  absolutely  dull  regions  of  the  liver,  heart,  and  spleen. 


To  face  page  36. 


THE  THORAX  37 

The  thoracic  regions  mentioned  above  are  twenty-six 
in  number,  and  are  the  following  : 

In  the  middle  line,  in  front  (four  regions)  :  lateral 
boundaries,  the  side-sternal  lines  ;  upper  sternal,  above 
the  angle  of  Ludwig  ;  midsternal,  from  the  second  to  the 
fourth  costal  cartilage ;  lower  sternal,  from  the  mid- 
sternal  to  the  point  of  the  xiphoid  cartilage  ;  epigastric, 
filling  the  angle  between  the  two  hypochondriacs  (re- 
lates chiefly  to  abdominal  organs). 

On  each  side,  in  front  (ten  regions) :  lateral  boundaries, 
the  side-sternal  and  anterior  axillary  lines ;  supra- 
clavicular;  clavicular  ;  infraclavicular ,  down  to  the  level 
of  the  third  costal  cartilage  ;  mammary,  down  to  the 
level  of  the  sixth  rib  in  the  nipple  line  ;  hypochondriac, 
down  to  the  costal  margin  (chiefly  abdominal) . 

At  the  sides  (four  regions)  :  between  the  anterior  and 
posterior  axillary  lines — axillary,  above  the  level  of 
the  sixth  rib  in  the  mid-axillary  line ;  infra-axillary, 
below  the  axillary. 

Behind  (eight  regions)  :  between  the  posterior  axillary 
line  and  the  spinal  line — suprascapular ;  scapular  (in- 
cludes the  supra-  and  infraspinous) ;  infrascapular ; 
interscapular. 

Examination  of  the  Thorax. — The  means  to  be  em- 
ployed are — inspection,  palpation,  mensuration,  per- 
cussion, auscultation,  and  in  some  cases  radiography. 
Pay  attention  first  to  the  shape,  size,  and  movements  of 
the  chest,  using  the  first  three  of  these  methods.  Ob- 
serve the  chest  in  a  good  light,  looking  at  it  from 
the  front,  back,  sides,  and  from  above  and  below.  In 
palpating  the  chest,  stand  to  the  right  of  the  patient,  who 
is  first  to  be  in  the  recumbent  position  ;  direct  him  to 
breathe  deeply,  to  cough,  to  speak,  while  the  hand  is 
in  contact  with  the  chest.     If  possible,  he  is  to  be 


38  SYSTEMATIC  CASE-TAKING 

examined  also  in  the  upright  posture.  In  some  cases 
it  is  desirable  to  measure  the  circumference  of  the  chest, 
or  to  make  an  outlined  tracing  of  its  shape  by  means  of 
the  cyrtometer,  an  instrument  composed  of  two  strips 
of  lead,  which  can  be  moulded  to  the  shape  of  the  chest, 
(usually  at  the  level  of  the  nipples),  and  the  figure 
transferred  to  paper. 

Abnormally  Shaped  Chests  do  not  necessarily  indi- 
cate disease  ;  they  may  result  from  past  ill-health  and 
faulty  development,  or  may  show  a  tendency  to  disease 
in  the  future. 

Diseases  in  childhood  causing  a  diminution  of  intra- 
thoracic pressure  give  rise  to  characteristic  deformities 
later  in  life.  The  chief  affections  of  this  nature  are 
adenoids,  enlarged  tonsils,  catarrh  of  the  nasal,  faucial, 
and  bronchial  passages,  all  of  which  cause  difficulty  of 
respiration  in  childhood,  and  so  prolong  the  period  of 
inspiration  when  intrathoracic  pressure  is  at  its  lowest, 
and  the  thoracic  walls  tend  to  bend  inwards  at  their 
least  resisting  parts.  The  results  are :  Harrison's 
sulcus,  or  the  transversely  grooved  chest,  a  fairly  hori- 
zontal depression  just  above  the  level  of  the  liver  ;  or 
it  may  take  the  form  of  simple  eversion  of  the  costal 
margins.  The  pigeon  breast :  the  front  of  the  chest  is 
narrow  and  keel-shaped.  The  rickety  chest :  a  vertical 
depression  on  each  side  of  the  front  of  the  chest,  the 
junctions  of  the  ribs  with  the  costal  cartilages  usually 
lying  at  the  base  of  the  groove  ;  tliese  joints  are  swollen, 
and  feel  like  a  string  of  beads  (the  rickety  rosary) .  The 
funnel  chest  (Trichterbrust) ,  Si  depression  of  the  lower  end 
of  the  sternum,  which  may  be  the  result  of  obstructed 
respiration  in  childhood,  of  pressure,  as  sometimes  occurs 
from  the  pressure  of  implements  among  shoemakers, 
or  it  may  be  congenital. 


THE  THORAX  39 

Developmental  dejects  are  seen  in  the  alar  chest,  in 
which  the  ribs  are  too  oblique,  the  shoulders  in  conse- 
quence sloping,  the  neck  long,  and  the  scapula  projecting 
and  wing-like  ;  in  the  fiat  chest,  with  the  anterior  por- 
tions of  the  ribs  and  costal  cartilages  flattened  instead 
of  convex  ;  and  sometimes  in  the  funnel  chest. 

Disease  actually  present  may  be  the  cause  of  thoracic 
deformities.  The  emphysematous  or  barrel  chest,  due  to 
prolonged  coughing  and  expiratory  dyspnoea  (usually 
chronic  bronchitis  or  asthma)  ;  the  chest  is  in  the 
position  of  very  full  inspiration.  Spinal  curvature 
distorts  the  shape  of  the  chest.  The  scoliotic,  the 
kyphotic,  the  scolio-kyphotic  chests,  show  the  deformities 
due  to  lateral  curvature  and  undue  posterior  convexity 
of  the  spinal  column.  Large  pleural  effusion  or  pneumo- 
thorax enlarge  the  affected  side,  obliterate  the  intercostal 
spaces,  raise  the  shoulder,  and  cause  the  spine  to  curve 
with  the  convexity  towards  the  effusion.  Enlargement 
of  abdominal  organs  may  produce  increase  in  size  of 
the  lower  chest.  Enlargement  of  the  heart  and  peri- 
cardium may  cause  precordial  bulging,  especially  among 
children.  Aneurisms,  mediastinal  or  other  tumours, 
may  produce  a  local  swelling.  Retraction  of  the  lung 
occurs  in  chronic  sclerotic  and  indurative  processes 
(chronic  phthisis,  chronic  pneumonia),  in  collapse  of 
the  lung,  and  after  the  absorption  of  a  copious  and 
long-continued  pleuritic  effusion.  The  affected  side  is 
retracted,  the  shoulder  lowered,  and  the  spine  concave 
towards  the  side  of  the  lesion.  In  phthisis  the  retrac- 
tion is  commonly  less  extreme  than  that  just  referred 
to,  and  usually  occurs  as  a  retraction  of  the  supra-  and 
infraclavicular  regions  of  one  or  both  lungs;  this  is 
most  readily  recognized  by  the  undue  prominence  of 
the  clavicles. 


40  SYSTEMATIC  CASE-TAKING 

Bulging  of  intercostal  spaces  is  sometimes  seen  in 
pleural  effusion,  in  pneumothorax,  and  in  asthma. 

Any  change  in  colour,  any  abnormal  or  enlarged  blood- 
vessels, any  obvious  enlargement  of  lymphatic  or  other 
glands,  any  tumour  or  other  deformity,  must  now  be 
noted,  as  far  as  they  relate  to  the  condition  of  the 
thorax. 

The  further  examination  of  the  chest  consists  almost 
entirely  of  a  study  of  the  respiratory  and  circulatory 
systems,  and  these  will  as  far  as  possible  be  taken 
separately. 


CHAPTER  IV 
RESPIRATORY  SYSTEM 

Dyspnoea — ^Altered  rhythm  of  respiration — Cough — Alterations 
in  the  voice — Vocal  fremitus — Percussion — Auscultation — 
Breath  sounds — ^Voice  sounds — Adventitious  sounds — Ex- 
amination of  the  sputum. 

A  MORE  detailed  examination  of  the  patient  is  now  to 
be  undertaken,  with  especial  regard  to  the  respiratory 
organs  and  to  any  derangement  of  their  functions  or 
structure  that  may  be  present.  Further  inquiry  should 
be  made  from  the  patient  as  to  any  relevant  subjective 
symptoms  which  he  may  have  noticed,  and  he  is  to  be 
examined  in  the  first  place  by  the  means  just  described 
{inspection,  palpation,  mensuration),  and  later  by  per- 
cussion, auscultation,  and,  if  necessary,  by  radiography. 

Dyspnoea. — ^Any  abnormality  in  the  act  of  breathing 
is  to  be  noted.  Many  diseased  conditions  in  addition 
to  those  of  the  respiratory  organs  cause  a  difficulty  in 
breathing  [dyspnoea),  owing  in  most  cases  to  defective 
oxidation  of  the  blood.  In  other  cases  irregularity  or 
disturbance  of  rhythm  occurs  without  obvious  dyspnoea. 
It  will  be  convenient  to  consider  here  abnormal  breathing 
arising  from  any  cause,  pulmonary  or  otherwise.  The 
dyspnoeic  conditions  will  be  first  described. 

Subjective  dyspnoea  is  the  sensation  of  "  shortness  of 
breath,"  by  which  the  individual  is  conscious  of  the 

41 


42  SYSTEMATIC  CASE-TAKING 

want  of  oxygen  ;  it  is  almost  always  associated  with 
obvious  signs  of  difficult  breathing  (objective  dyspnoea). 
In  hysterical  and  neurotic  persons  the  subjective  sen- 
sation is  usually  out  of  proportion  to  the  objective 
signs. 

Objective  dyspnoea  is  of  much  more  value  in  diagnosis. 
The  chief  features  to  be  recognized  are  increased  or 
decreased  frequency  of  respiration,  increased  or  de- 
creased force,  altered  rhythm  of  respiration,  exag- 
gerated movements  of  respiratory  muscles,  active  move- 
ments of  the  alae  nasi,  stridor,  cyanosis. 

Normally  the  respirations  in  adults  occur  i6  to  20 
times  per  minute  ;  in  children  of  five  years,  25  per 
minute  ;  and  at  birth,  45  per  minute. 

Increased  frequency  of  respiration  is  the  commonest 
form  in  which  dyspnoea  appears,  and  occurs  in  all  those 
cases  in  which  the  amount  of  lung  tissue  available  for 
aeration  is  diminished — e.g.,  phthisis,  pneumonia,  capil- 
lary bronchitis,  pleural  effusion,  pulmonary  embolism 
and  infarction,  oedema  and  passive  congestion  of  the 
lungs,  pneumothorax,  mediastinal  and  other  tumours 
causing  pressure  on  the  lungs.  Difficulty  in  the  act  of 
respiration,  owing  to  pain  in  the  chest,  injuries  to  the 
chest  walls,  or  obstruction  of  the  upper  air  passages, 
cause  increased  frequency  of  respiration.  The  red 
blood  cells  may  be  insufficient  in  quantity  or  in  haemo- 
globin, as  in  chlorosis,  and  other  forms  of , anaemia,  and 
haemorrhage.  The  blood  may  be  imperfectly  aerated 
owing  to  disease  of  the  heart  or  lungs ;  venous  blood 
reaching  the  respiratory  centre  acts  as  a  powerful 
stimulant  to  the  centre.  Blood  which  contains  bacterial 
or  other  toxins,  which  has  been  imperfectly  purified  by 
the  excretory  organs,  or  which  is  of  an  unduly  high 
temperature,  probably  stimulates  excessively  the  respir- 


RESPIRATORY  SYSTEM  43 

atory  centre — e.g.,  pneumonia,  Bright's  disease,  diabetes, 
and  fevers. 

The  readiness  with  which  dyspnoea  of  this  description 
is  produced  in  those  whose  breathing  when  at  rest  is 
natural,  forms  a  fair  index  of  the  gravity  of  the  lesion, 
or,  in  the  case  of  heart  affections,  of  the  degree  of 
compensation  which  has  been  established. 

Decreased  frequency  of  respiration  is  less  commonly 
seen.  It  may  occur  in  emphysema  and  asthma,  in 
which  cases  it  is  chiefly  the  expiratory  part  that  is 
prolonged.  A  slow,  sighing  type  of  breathing  may  be 
seen  in  the  dyspnoea  of  shock,  syncope,  haemorrhage, 
and  in  hysteria.  Moribund  patients  have  a  slow, 
irregular,  intermittent  respiration  ;  poisoning  by  opium, 
chloral,  chloroform,  and  aconite  causes  slow  respiration. 

Increased  force  of  breathing  is  usually  seen  with  slow 
breathing,  but  in  some  cases  rapid  breathing  may  be 
energetic  and  deep — e.g.,  the  dyspnoea  of  anaemia, 
diabetes,  and  heart  disease.  The  slow  breathing  of 
shock,  hysteria,  and  intracranial  disease,  may  be  un- 
duly forcible. 

Altered  Rhythm  of  Respiration. — ^Normally  the  act 
of  expiration  lasts  a  little  longer  than  inspiration,  in 
the  ratio  of  about  6  to  5,  and  a  slight  pause  ensues 
after  expiration,  unless  the  breathing  be  hurried.  The 
inspiratory  portion  especially  of  the  act  of  respiration 
may  be  impeded  and  prolonged  in  conditions  which 
obstruct  the  free  entrance  of  air  to  the  lungs — laryngeal 
or  tracheal  obstruction.  Stridor,  recession  of  the  supra- 
clavicular fossae  and  of  the  epigastrium  and  lower  inter- 
costal spaces,  and  prolonged  inspiration,  are  the  chief 
features  of  this  disturbance  of  respiration.  On  the 
other  hand,  expiration  may  be  prolonged  and  difficult, 
with  bulging   of   the   supraclavicular  fossae   and   epi- 


44  SYSTEMATIC  CASE-TAKING 

gastrium,  and  excessive  action  of  the  abdominal  muscles. 
This  arises  from  want  of  elasticity  of  the  lungs  and 
thoracic  walls,  and  is  seen  in  chronic  bronchitis,  em- 
physema, and  asthma. 

Irregularity  in  the  rhythm  of  breathing  as  regards 
force  and  the  length  of  intervals  between  separate 
breaths  occurs  in  hysteria,  heart  failure,  cerebral  haemor- 
rhage, brain  tumours,  meningitis,  etc.  A  more  method- 
ical irregularity  is  seen  in  Cheyne-Stokes  respiration : 
alternating  phases  of  weak  and  forcible  breathing,  the 
movements  of  respiration  being  entirely  stopped  during 
a  short  period,  then  gradually  gaining  strength  till  they 
become  exaggerated,  and  then  by  degrees  weakening  till 
they  cease  again.  It  may  be  observed  during  sleep  or 
unconsciousness,  or  the  patient  may  lapse  into  stupor 
during  the  apnoeic  or  quiet  interval.  While  it  is  usually 
an  ominous  symptom,  in  many  cases  the  condition 
passes  away  as  the  patient's  health  improves.  It  is 
found  in  serious  intracranial  disease,  heart  affections, 
kidney  disease,  opium-poisoning,  and  other  toxic  states 
threatening  life.  A  somewhat  similar  type  of  breathing, 
in  which,  at  intervals  of  variable  duration,  the  breathing 
may  stop  for  perhaps  half  a  minute,  is  termed  Biot's 
respiration  ;  it  may  occur  in  cerebral  meningitis  and 
other  grave  disorders. 

Stertorous  dyspnoea  may  be  mentioned ;  it  is  caused 
by  noisy  vibrations  of  the  soft  palate  while  breathing 
through  the  mouth,  and  is  heard  during  unconsciousness, 
either  of  sleep  or  of  coma — e.g.,  cerebral  apoplexy, 
uraemic,  diabetic,  alcoholic,  narcotic,  and  ante-mortem 
coma. 

Decreased  activity  of  respiration  is  rarely  a  form  of 
dyspnoea.  The  extent  of  the  movements  of  respiration 
may  be  limited  locally  or  generally  by  painful  conditions. 


RESPIRATORY  SYSTEM  45 

by  mechanical  obstruction,  by  nerve  lesions,  by  de- 
velopmental defects,  etc.  Thus  we  find,  on  careful 
observation  of  the  chest  that  the  movements  as  a 
whole,  or  possibly  of  one  side  only,  may  be  defective 
in  cases  of  pleurisy  (with  or  without  effusion),  emphy- 
sema, pericarditis,  peritonitis,  fracture  of  the  ribs, 
pleurodynia,  paralytic  conditions  (spinal  disease,  peri- 
pheral neuritis),  and  ankylosis  of  the  costal  articula- 
tions in  arthritis  deformans.  In  debility  and  collapse 
the  breathing  is  shallow.  Unilateral  or  localized  im- 
mobility is  seen  in  affections  which  prevent  the  proper 
expansion  of  the  lung,  as  phthisis,  pleural  adhesions 
and  effusions,  pneumothorax,  collapse  of  the  lung, 
pneumonia,  obstruction  of  a  bronchus,  etc. 

Cough. — ^The  sudden  explosive  expiration  is  a  reflex 
act  arising  from  some  irritation  applied  to  sensory 
nerve  endings,  usually,  but  not  invariably,  in  the  mucous 
membrane  of  the  respiratory  tract,  some  portion  of  which 
— e.g.,  interarytenoid  mucous  membrane  and  that  at  the 
bifurcation  of  the  trachea  —  are  more  sensitive  than 
others.  The  stimulus  may,  however,  arise  from  other 
sensory  regions,  which  have  apparently  little  connection 
with  the  respiratory  system,  as  the  external  auditory 
meatus,  the  stomach,  the  ovaries.  In  coughs  arising 
from  these  more  distant  regions  it  is  possible  that  the 
general  nervous  system  is  unusually  sensitive.  This 
so-called  nervous  cough  is  a  short,  dry,  oft-repeated 
effort,  which,  apparently,  becomes  a  habit.  A  similar, 
but  more  pronounced  and  insistent,  bark  is  the  hysterical 
cough,  which,  though  largely  of  emotional  origin,  has 
usually  some  peripheral  irritation — possibly  a  very 
trivial  one — for  its  cause. 

The  loose  cough  is  a  successful  and  fruitful  cough ; 
a  hard  or  dry  cough  accomplishes  nothing.     A  harsh, 


46  SYSTEMATIC  CASE-TAKING 

hoarse,  or  metallic  quality  of  cough  points  to  the  larynx 
as  the  seat  of  the  irritation.  A  paroxysmal  cough  is 
also  the  result  of  laryngeal  irritation,  or  may  be  due  to 
the  pressure  of  tumours. 

Inability  to  cough  may  result  from  abdominal  dis- 
tension, from  pleurisy,  from  paralysis  of  the  vocal  cords, 
from  paralysis  of  muscles  of  respiration,  and  from  grave 
prostration. 

Alterations  in  the  Voice  are  caused  by  disease  of  the 
lar5mx  or  of  its  nervous  supply,  by  disorders  of  the 
respiratory  passages  and  mouth,  and  by  general  dis- 
turbances of  health.  In  examination  the  laryngoscope 
is  to  be  used. 

Hoarseness  and  Loss  of  Voice  (Aphonia)  arise  from 
any  interference  with  the  proper  vibrations  of  the  vocal 
cords,  the  commonest  cause  being  laryngeal  catarrh. 
It  may  occur  in  diphtheria,  syphilis,  tuberculosis, 
tumours  of  the  larynx,  cicatricial  contractions,  foreign 
bodies,  oedema  of  the  glottis,  inflammatory  or  malignant 
disease  of  the  oesophagus  or  phar5mx,  paralysis  of  the 
vocal  cords  from  disease  or  injury  of  the  laryngeal 
nerves  (superior  and  inferior,  branches  of  the  vagus) 
or  of  their  central  connections.  The  course  of  the 
inferior  laryngeal  nerve,  which  innervates  almost  all 
the  laryngeal  muscles,  renders  the  vocal  cords  very 
liable  to  paralysis  from  aneurism  of  the  aorta  or  right 
subclavian  artery,  or  from  mediastinal  tumours. 
Pleurisy  or  phthisis  of  the  apex  of  the  lung  may  also  be 
a  source  of  irritation  or  pressure  to  the  recurrent  nerve, 
especially  on  the  right  side. 

Nasal  Voice. — Obstructions  in  the  nasal  passages 
interfere  with  the  proper  resonance  of  the  voice,  or  give 
a  nasal  quality  to  the  word  spoken — the  so-called 
closed  nasal  voice.     On  the  other  hand,  inability  to 


RESPIRATORY  SYSTEM  47 

shut  off  the  pharyngeal  from  the  nasal  cavity,  as  occurs 
in  paralysis  of  the  soft  palate,  causes  the  open  nasal 
voice — that  is,  talking  through  the  nose. 

Debility  from  any  cause  is  often  indicated  by  weakness 
of  the  voice.  Hysteria  has  been  already  mentioned  as 
a  cause  of  aphonia. 

Vocal  Fremitus. — A  trembling  movement  of  the  chest 
surface  produced  by  the  act  of  speaking.  With  the 
hand  laid  flat  upon  the  chest,  the  patient  is  instructed 
to  say  the  words  "  nine  "  or  "  ninety-nine,''  which,  by 
imparting  a  nasal  quality  to  the  sound,  favour  the  pro- 
duction of  vibrations.  Normally  these  vibrations  are 
conveyed  from  the  larynx  through  the  air  channels  in 
the  lungs  (bronchi)  and  the  spongy  texture  of  these 
organs,  thence  to  the  chest  wall.  The  distinctness  with 
which  these  movements  are  felt  is  favoured  by — (i)  a 
low-pitched,  loud  note ;  (2)  the  presence  of  good  con- 
ducting material  between  the  larynx  and  the  chest  wall. 
Columns  of  air,  as  found  in  the  larger  bronchi,  are 
excellent  conductors  of  sound  vibrations.  The  spongy 
mass  of  air  cells  in  the  lung  is  a  poor  conductor,  but  its 
conducting  quality  is  improved  either  by  relaxation  of 
the  lung  tissue  or  by  its  replacement  by  a  more  solid 
mass,  such  as  is  found  in  consolidation  of  the  lung  from 
inflammation,  particularly  if  the  consolidated  mass  is 
traversed  by  open  air  tubes. 

On  the  other  hand,  a  high-pitched  and  weak  voice, 
or  the  presence  of  non-conducting  material  between  the 
source  of  the  vibrations  (larynx)  and  the  chest  wall, 
such  as  pleural  effusion,  fatty  chest  wall,  oedema, 
interfere  with  vocal  fremitus. 

LiUen's  Sign. — Place  the  patient  on  his  back  with 
his  feet  toward  the  light,  other  side-lights  being  re- 
moved ;  a  linear  shadow  at  right  angles  to  the  mid- 


48  SYSTEMATIC  CASE-TAKING 

axillary  line  is  then  seen  moving  downward  with  in- 
spiration, and,  less  distinctly,  upward  with  expiration. 
The  distance  traversed  by  the  shadow  may  be  from  the 
sixth  to  the  ninth  rib.  It  is  produced  by  a  sucking-in 
of  the  intercostal  spaces  as  the  diaphragm  descends, 
and  its  presence  is  proof  that  the  lung  and  the  diaphragm 
lie  against  the  thoracic  wall  at  that  spot,  and  are  free 
to  move.  Its  absence  in  patients  whose  chest  walls  are 
not  thickly  covered  with  muscle  or  fat  suggests  pleural 
effusion,  pleural  adhesion,  pneumothorax,  pneumonia. 

Percussion. — ^The  sounds  elicited  by  a  stroke  of  the 
fingers  or  of  a  specially  designed  hammer  (plessor) 
acquire  a  musical  quality  or  resonance,  owing  to  the 
presence  of  enclosed  air.  The  vibrations  caused  by 
the  blow  acquire  a  regularity  of  rhythm,  owing  to  the 
resounding  qualities  of  the  air  channels.  The  result  is, 
as  in  many  musical  instruments,  a  musical  note  of 
resonance  instead  of  a  noise.  The  degree  of  resonance 
varies,  and  depends  mainly  upon  the  resounding  qualities 
of  the  objects  struck,  collections  of  air  forming  the  best 
resounding  medium.  Bone  is  a  moderately  good  re- 
sounding body,  but  soft  tissues  have  no  resonant  quality. 
Practically,  resonance  depends  upon  the  presence  of 
collections  of  air  in  the  immediate  vicinity  of  the  spot 
struck.  Percussion  is  practised  almost  exclusively  by 
the  so-called  mediate  method — that  is,  the  hammer 
(usually  the  middle  finger  of  the  right  hand)  does  not 
strike  the  part  immediately,  but  an  intermediate  instru- 
ment called  the  "  pleximeter."  The  latter  may  be 
composed  of  bone,  vulcanite,  cork,  or  other  material ; 
but  most  examiners  prefer  to  use  a  finger  of  the  left 
hand,  which  is  placed,  palmar  surface  downward,  firmly, 
but  not  too  forcibly,  upon  the  portion  of  the  body  under 
examination.     One  or  two  fingers  of  the  right  hand 


RESPIRATORY  SYSTEM  49 

bent  at  a  suitable  angle  form  the  hammer  or  plessor, 
sharp  taps  being  delivered  from  the  wrist  with  a  staccato 
movement  and  with  varying  force.  The  use  of  the 
finger  as  a  pleximeter  has  the  additional  advantage  of 
conveying  to  the  observer  information  as  to  the  con- 
dition of  resistance  or  tone  of  the  part.  In  determining 
the  boundaries  of  the  organs  by  means  of  percussion, 
it  is  best  to  percuss  first  the  more  resonant  regions, 
advancing  the  pleximeter  finger  in  a  line  at  right  angles 
to  the  boundary  which  is  to  be  determined.  Careful 
comparison  of  similar  regions  on  each  side  of  the  body, 
due  consideration  being  given  to  the  anatomical  relations 
of  the  organs,  is  of  the  utmost  importance. 

Generally  speaking,  a  forcible  blow,  a  large  collection 
of  air  under  moderate  pressure,  and  a  smooth  wall 
cavity,  all  favour  a  high  degree  of  resonance  or  musical 
quality,  which,  being  of  a  drum-like  character,  is  spoken 
of  as  a  tympanitic  note,  or  hyper -resonance.  This  is  the 
sound  produced  by  percussing  over  the  stomach.  In 
the  lung  the  air  chambers  are  small  and  divided  by 
innumerable  membranous  septa,  which,  being  in  a  high 
state  of  tension,  are  imperfect  resounding  media ;  the 
percussion  note  of  the  lung  is  therefore  less  resonant 
than  that  just  mentioned,  and  is  generally  spoken  of 
as  a  subtympanitic  note. 

If  the  stroke  is  delivered  over  a  solid  organ,  such  as 
the  liver  or  heart,  there  is  an  absence  of  the  resounding 
quality,  and  a  dull  note  or  noise  results  (dulness). 

That  portion  of  the  chest  wall  which  is  in  contact  with 
the  lung  is  spoken  of  as  the  pulmonary  region.  It  ex- 
tends from  about  ij  inches  above  the  clavicles  to  the 
level  of  the  base  of  the  lung  on  each  side,  which  during 
quiet  breathing  is  at  the  sixth  rib  in  the  nipple  line, 
eighth  in  the  mid-axillary  line,  tenth  in  the  scapular 

4 


50  SYSTEMATIC  CASE-TAKING 

line.  On  the  left  side  in  front,  the  anterior  edge  of  the 
left  lung  deviates  from  the  middle  line  at  the  level  of 
the  fourth  costal  cartilage,  curving  out  to  the  apex  of 
the  heart  about  3|  inches  from  the  middle  line,  leaving 
a  triangular  area,  called  the  area  of  superficial  cardiac 
dulness  (A.S.C.D.),  over  which  the  percussion  note  is  dull. 

That  portion  of  the  thorax  in  contact  with  the  stomach 
is  called  Traube's  semilunar  space.  It  is  bounded  above 
by  the  base  of  the  left  lung,  the  heart's  apex,  and 
the  left  lobe  of  the  liver  ;  below  and  internally  by  the 
left  costal  margin ;  and  externally  by  the  splenic  dulness. 

The  sounds  obtained  by  percussion  may  be  altered 
by  disease  in  various  ways  : 

Increased  Resonance,  due  to  excessive  activity  and 
force  of  the  resonant  vibrations.  This  is  found  in — 
(i)  Emphysema  of  the  lung.  The  resonance  in  this  con- 
dition is  drum-like,  giving  a  sound  like  that  obtained 
by  striking  an  empty  cardboard  box  {box  note).  (2)  Re- 
laxation of  the  lung.  The  healthy  lung  is  in  a  state  of 
extreme  tension.  Any  condition  which  reduces  the 
capacity  of  the  thorax  permits  the  lung  to  relax,  causing 
a  more  resonant  note.  Thus  in  cases  of  pleural  effusion, 
above  the  level  of  the  fluid,  the  percussion  note  has  a 
somewhat  high-pitched,  clear  quality — the  so-called 
skodaic  resonance.  (3)  Pulmonary  cavities,  if  large, 
superficial,  and  recently  emptied  by  expectoration, 
become  h3rper-resonant.  Other  modifications  of  the 
note  produced  by  pulmonary  cavities  are  referred  to 
below.  (4)  Pneumothorax,  a  large  collection  of  air  in 
the  pleural  cavity,  causes  a  loud  and  resonant  note, 
unless  the  air  should  be  under  high  pressure,  as  is  often 
the  case,  owing  to  a  valve-like  communication  between 
the  pleural  cavity  and  a  bronchus.  In  this  case  the 
percussion  note  is  only  of  moderate  resonance. 


RESPIRATORY  SYSTEM  51 

Diminished  Resonance. — i.  A  reduction  in  the  quan- 
tity of  air  in  the  lung  lessens  the  resonance  of  the  stroke. 
This  condition  may  be  caused  by  infiltration  of  the  lung 
with  the  products  of  inflammation  ;  hence  pneumonia 
(commonest  at  the  base)  and  phthisis  (oftenest  at  the 
apex)  cause  diminished  resonance.  Passive  congestion 
of  the  lung  may  give  rise  to  dulness,  and  may  be  found 
in  prolonged  debilitating  diseases  or  in  heart  disease. 
Other  conditions,  less  frequently  met  with,  producing 
this  abnormal  dulness  are  infarction,  oedema,  collapse, 
or  cirrhosis  of  the  lungs.  Compression  of  the  lung  by 
pleural  effusion  or  by  tumours  of  the  thorax,  and  the 
presence  of  the  tumours  themselves,  cause  a  dulled 
percussion  note. 

2.  A  decrease  in  the  actual  quantity  of  lung  tissue 
from  disease,  of  which  some  instances  have  just  been 
mentioned,  is  another  cause  of  diminished  resonance. 

3.  The  interposition  of  airless  material  between  the 
lung  and  the  surface  is  a  common  cause  of  dulness — e.g., 
thickened  pleura  and  pleural  effusion. 

In  cases  of  pleurisy  with  effusion  it  is  noticed  that 
the  fluid  does  not  strictly  follow  the  lines  of  gravity. 
The  fluid  is  found,  even  in  patients  who  remain  in  the 
upright  position,  to  rise  highest  in  the  scapular  or  mid- 
axillary  lines,  falling  as  it  passes  forward,  and  to  a  less 
extent  as  it  approaches  the  median  line  behind.  This 
position  of  the  fluid  results  mainly  from  the  tendency 
of  the  liquid  to  follow  the  line  of  least  resistance,  which, 
in  this  case,  means  the  replacing  or  compression  of  the 
most  voluminous  part  of  the  lung  by  the  fluid  at  the 
back  and  sides  of  the  lower  part  of  the  lung.  The  curved 
line,  representing  the  upper  level  of  the  fluid,  is  known 
as  Ellis's  or  Garland's  line.  This  line  can  best  be 
demonstrated  when  the  chest  is  moderately  full  of  fluid. 


52  SYSTEMATIC  CASE-TAKING 

In  hydrothorax,  where  the  fluid  is  not  the  result  of 
pleuritis,  it  obeys  more  closely  the  laws  of  gravitation  ; 
hence  we  may  partly  ascribe  Ellis's  line  to  pleuritic 
adhesions. 

The  dulness  due  to  an  effusion  of  blood  in  the  pleural 
cavity  (hsemothorax)  resembles  that  of  hydrothorax. 
It  does  not  usually  coagulate  for  several  days,  and  unless 
fixed  by  adhesions  it  is  quite  movable. 

An  unusually  thick  chest  wall  (muscle,  fat,  oedema) 
deadens  the  resonant  note.  Alterations  in  the  per- 
cussion note  due  to  affections  or  displacements  of  the 
heart  are  referred  to  in  Chapter  V. 

Changes  in  Quality  or  Tone. — ^The  presence  of  a  smooth- 
walled,  fairly  large  cavity — e.g.,  pneumothorax  or  a  pul- 
monary cavity — ogives  a  reverberating  quality  to  the 
percussion  note,  known  as  amphoric  or  metallic  resonance. 

On  percussing  over  a  pulmonary  cavity  connected 
with  the  bronchus,  the  resulting  tympanitic  or  amphoric 
note  is  raised  in  pitch  if  the  patient  open  his  mouth, 
and  the  pitch  is  lowered  when  the  mouth  is  closed 
{Wintrich's  sign).  The  same  phenomena  may  be 
observed  at  times  in  percussing  the  apex  of  the  lung 
in  consolidation  of  that  region  {Williamson's  tracheal 
resonance). 

Bell  Sound. — If  the  chest  be  percussed,  using  a  coin 
as  pleximeter  and  another  as  plessor,  a  sound  is  normally 
heard  by  the  stethoscope  of  a  metallic  character.  In 
conditions  where  a  large  collection  of  air  is  found  in 
the  chest,  and  particularly  in  pneumothorax,  the 
sound  acquires  a  clear,  bell-like  quality. 

Cracked-Pot  Sound. — A  percussion  sound  which  is 
usually  an  indication  of  a  cavity  in  the  lung.  The  per- 
cussion stroke,  driving  the  air  from  the  cavity  into  a 
bronchus,  causes  a  squeaking  or  chinking  sound,  which. 


RESPIRATORY  SYSTEM 


53 


once  heard,  can  easily  be  recognized.  A  similar  quality 
of  percussion  sound  can  be  produced  by  percussing  the 
chest  of  a  healthy  infant,  particularly  during  forcible 
expiration  or  crying.  In  this  case  it  is  the  air  escaping 
at  high  pressure  from  the  glottis  which  causes  the  sound. 
Its  resemblance  to  the  note  produced  by  striking  a 
cracked  vessel  or  bell  is  the  origin  of  the  name. 

Changes  in  the  extent  of  the  resonant  area  of  the 
thorax  as  compared  with  the  healthy  chest  must  be 
observed.  The  pulmonary  region  may  be  increased  in 
extent,  as  is  seen  in  emphysema  and  pneumothorax  ; 
in  these  conditions  the  area  of  cardiac  dulness  may  be 
diminished  or  abolished,  and  the  liver  and  spleen 
dulness  may  be  encroached  on  by  the  resonant  areas. 
A  diminution  of  the  extent  of  resonance  is  another 
mode  of  expressing  the  occurrence  of  dulness  where 
resonance  ought  to  be  found.  The  conditions  which 
give  rise  to  it  are  those  enumerated  above  in  discussing 
diminished  resonance. 

Auscultation. — It  is  possible  to  obtain  most  of  the 
evidence  required  by  the  unaided  ear,  but  for  various 
reasons  the  use  of  an  instrument  (the  stethoscope)  is 
desirable.  Many  clinicians  still  prefer  the  single  stetho- 
scope. There  can,  however,  be  no  doubt  that  the 
binaural  instrument  offers  advantages  in  almost  every 
case. 

Care  must  be  taken,  when  placing  the  bell  of  the 
stethoscope  upon  the  body,  that  it  press  evenly  and 
firmly,  but  lightly,  upon  the  surface.  Movement  of  the 
chest-piece  upon  the  skin  must  be  avoided,  and  the 
serious  inconvenience  caused  by  a  hairy  surface  can  be 
mitigated  by  anointing  the  skin  with  vaseline  or  other 
lubricant. 

There  are  three  groups  of  audible  symptoms  resulting 


54  SYSTEMATIC  CASE-TAKING 

from  respiration  which  have  to  be  noted :  (i)  The 
sounds  produced  by  the  act  of  respiration  in  diseased 
conditions  ;  (2)  the  voice  sounds  as  modified  by  disease  ; 
(3)  the  various  new  or  adventitious  sounds  produced 
in  connection  with  disease  of  the  lungs. 

I.  Breath  Sounds. — The  normal  sound  produced  by 
breathing  when  one  listens  over  a  region  of  the  lung 
distant  from  the  larger  air  channels  may  be  easily 
recognized  as  a  sighing,  whispering  rustle  {vesicular 
breathing),  coinciding  almost  entirely  with  the  act  of 
inspiration.  During  expiration  this  sound  is  only 
heard  in  the  earliest  portion,  and  usually  lasts  about 
one-third  or  less  of  the  time  occupied  by  the  inspiratory 
breath  sound  ;  the  short  expiratory  portion  is  softer 
and  somewhat  lower  pitched  than  the  inspiratory. 
Often  a  faint,  soft  sound  persists  during  the  whole  of 
expiration. 

When  one  places  the  stethoscope  nearer  the  trachea 
and  larger  bronchi — e.g.,  near  the  sternum,  in  the  upper 
part  of  the  chest — and  behind,  close  to  the  upper  three 
or  four  dorsal  vertebrae,  the  sound  has  a  harsh  to-and-fro 
quality — ^the  so-called  tracheal  or  bronchial  breathing. 
The  farther  from  the  larynx  one  places  the  stethoscope, 
the  less  distinct  is  this  sound,  as  a  larger  quantity  of 
imperfectly  conducting  lung  tissue  is  interposed,  until, 
on  listening  over  the  sides  or  bases  of  the  lung,  one 
hears  the  characteristic  vesicular  breath  sounds. 

Increased  Breath  Sounds. — The  sounds  may  be  louder 
than  normal,  either  owing  to  the  increased  production 
of  the  sound  or  to  an  improved  conduction  of  the 
vibrations.  Excessive  action  such  as  occurs  when  one 
lung  sustains  most  of  the  respiration,  owing  to  disease 
of  the  other  lung,  causes  increased  breath  sounds — the 
so-called  puerile  breathing.     The  sounds  are  more  in- 


RESPIRATORY  SYSTEM  55 

tense  in  forced  breathing,  in  dyspnoea,  in  narrowing  of 
the  rima  glottidis,  in  external  or  internal  obstruction 
of  the  trachea  or  larger  bronchi. 

Improved  conduction  increases  the  loudness  of  breath 
sounds  when  a  portion  of  the  spongy  lung  tissue  is 
replaced  by  a  more  homogeneous  texture,  as  occurs 
in  pneumonic  or  tubercular  infiltrations,  in  excavation, 
in  tumours,  in  compression,  and,  to  a  less  degree,  in 
relaxation  of  the  lung.  Unduly  thin  walls  similarly 
transmit  intensified  breath  sounds. 

Broncho-Vesicular  Breathing. — Increased  breath  sound 
generally  takes  the  form  of  bronchial  rather  than  louder 
vesicular  breathing.  When  the  increased  intensity  is 
only  moderate,  it  may  consist  in  inspiratory  vesicular 
breathing,  with  either  prolonged  expiration  or  an  actual 
bronchial  quality  of  the  expiratory  portion.  This  is 
known  as  "  transitional,"  "  indeterminate,"  or  "  mixed  " 
breathing.  Prolongation  of  the  expiratory  portion 
may  be  the  only  evidence  of  increased  intensity  of 
breathing.  At  the  right  apex  breathing  is  normally 
harsher  than  at  the  left,  owing  to  the  anatomical  rela- 
tions of  the  bronchi.  Bronchial  breathing  heard  at  the 
lower  part  of  the  chest,  and  especially  at  the  sides  and 
back,  may  indicate  pleural  effusion,  as  the  fluid  causes 
relaxation  of  the  lung.  The  lung  in  this  relaxed  con- 
dition is  a  better  conductor  of  sound  than  in  the  normal 
state.  If  the  breathing  be  tubular,  a  complete  con- 
solidation with  open  bronchi  is  probable.  If  the  breath 
sounds  be  not  only  bronchial,  but  also  cavernous  (see 
below),  a  cavity  may  be  diagnosed  if  the  evidence 
obtained  by  percussion  corroborates. 

Decreased  Breath  Sounds  result  from  either  deficient 
production  or  imperfect  conduction.  The  former  occurs 
in  debility,  pneumothorax,  emphysema,  a  flattened  or 


56  SYSTEMATIC  CASE-TAKING 

badly-developed  chest,  pleurisy,  peritonitis,  intercostal 
rheumatism,  neuralgia,  or  fractured  ribs.  Defective 
conduction  is  found  in  conditions  where  the  air  passages 
are  completely  blocked,  as  in  massive  pneumonia,  or 
where  an  inferior  conducting  material  lies  between  the 
bronchi  and  the  surface  of  the  thorax,  such  as  pleural 
effusion,  thickened  pleura,  tumour,  and  thick  chest  walls. 

A  variety  of  abnormal  qualities  of  the  breathing,  in- 
dependent of  the  degree  of  loudness,  have  to  be  noted  : 

Tubular  Breathing,  a  clear,  high-pitched  quality  of 
breath  sound,  caused  partly  by  the  good  conducting 
qualities  of  consolidated  lung,  and  partly  produced  in 
the  affected  tissue  by  the  passage  of  air  over  the  open 
mouths  of  bronchi. 

Cavernous  Breathing,  a  curious  reverberating  quality 
of  breathing  heard  over  a  large  air  cavity.  A  somewhat 
similar  sound,  resembling  that  produced  by  blowing 
across  the  opening  of  a  narrow-mouthed  vase  or  wide- 
mouthed  bottle,  is  termed  amphoric  breathing. 

Cog-Wheel  Breathing,  an  intermittent,  vesicular  breath 
sound,  heard  chiefly  in  inspiration.  If  localized,  it  may 
be  the  result  of  obstruction  in  the  bronchioles,  and  is 
found  in  bronchial  catarrh  and  in  late  phthisis. 

Metamorphosed  Breath  Sounds. — A  change  in  the 
breath  sounds  may  be  observed  at  times ;  inspiration 
may  begin  as  a  harsh  or  bronchial  murmur,  becoming 
softer  as  it  proceeds,  or  it  may  acquire  a  cavernous  char- 
acter. This  change  is  due  to  the  partial  distension 
during  inspiration  of  a  cavity  in  the  lung.  Other 
changes  in  the  breath  sound  may  be  observed;  thus 
Lsennec's  veiled  puff  [souffle  voile)  is  a  sudden  change 
in  the  intensity  or  quality  of  the  sound,  owing  to  the 
temporary  removal  of  a  plug  or  curtain  of  mucus  from 
a  partially  blocked  bronchus. 


RESPIRATORY  SYSTEM  57 

Stridor,  a  noisy  breath  sound,  caused  by  an  obstruc- 
tion in  the  bronchi,  trachea,  or  larynx,  and  most  fre- 
quently heard  during  inspiration.  The  respiratory 
difficulty  is  obvious,  as  seen  by  the  exaggerated  move- 
ments of  respiration  (see  Dyspnoea,  above). 

2.  Voice  Sounds. — On  listening  over  the  chest  whilst 
the  patient  speaks,  a  droning,  buzzing  quality  of  voice 
is  heard,  in  which  the  articulation  of  words  and  syllables 
can  hardly  be  distinguished.  This  is  known  as  Vocal 
Resonance,  and  over  those  regions  of  the  chest  in  which 
loud  or  bronchial  breathing  is  normally  heard  the  voice 
sound  is  loud,  and  gives  one  the  impression  of  being 
generated  at  the  surface  practically  under  the  stetho- 
scope. 

Increased  Vocal  Resonance  usually  indicates  consoli- 
dation of  the  lung,  and  is  termed  bronchophony. 

Decreased  Vocal  Resonance  is  caused  by  diminished 
conductivity  of  the  tissues  of  the  chest — e.g.,  pleural 
effusion,  thickened  pleura,  unusually  thick  chest  walls, 
an  obstructed  bronchus,  and  emphysema. 

Pectoriloquy,  an  unusually  distinct  and  articulate 
voice  sound,  and  whispering  pectoriloquy,  a  similar  dis- 
tinctness of  whispered  speech,  observed  in  conditions 
in  which  the  conduction  is  exceptionally  good.  A  pul- 
monary cavity  communicating  freely  with  a  bronchus, 
and  surrounded  by  an  area  of  consolidation,  is  likely  to 
produce  this  sign. 

Mgophony. — A  nasal  or  whining  quality  of  voice, 
often  heard  over  the  situation  of  pleural  effusion, 
especially  at  its  upper  limits.  Occasionally  it  is  heard 
over  pulmonary  consolidation. 

3.  Adventitious  Sounds. — On  listening  over  the  res- 
piratory organs,  certain  sounds  may  be  noticed  which 
cannot  be  described  as  mere  modifications  of  the  voice 


58  SYSTEMATIC  CASE-TAKING 

or  breath  sounds.  They  may  be  classified  as  follows : 
(i)  Rhonchi;;  (2)  rales  ;  (3)  friction  sound ;  (4)  bell  sound  ; 
(5)  metallic  tinkling ;  (6)  succussion  sound. 

(i)  Rhonchi  are  musical  sounds  heard  during  the  act 
of  breathing.  The}^  result  from  localized  narrowing  of 
the  calibre  of  the  bronchi  by  the  deposition  in  the  tubes 
of  mucus,  by  thickening  of  their  lining  membrane,  or 
by  spasm  of  their  muscular  coat.  Thus,  sounds  produced 
in  the  larger  bronchi  are  low-pitched,  and  are  termed 
sonorous  rhonchi  ;  whilst  those  originating  in  the  smaller 
bronchi  have  a  higher  pitch,  and  are  termed  sibilant 
rhonchi.  When  heard  over  large  areas  of  the  chest,  they 
are  a  sign  of  bronchitis,  asthma,  or  more  rarely  of 
phthisis.  In  asthma  the  sounds  are  mostly  sibilant, 
chiefly  heard  in  the  prolonged  expiratory  act.  When 
localized,  and  particularly  at  the  apex  of  a  lobe,  rhonchi 
suggest  early  phthisis. 

(2)  Rales. — Crackling,  rattling,  or  bubbling  sounds 
may  be  heard.  The  term  ''  rale  "  (French,  "  rattling 
noise  ")  may  be  used  to  include  many  different  varieties 
of  these  sounds.  Crepitant  rales,  fine  crackling  sounds, 
heard  chiefly  during  inspiration.  They  may  be  imitated 
by  rolling  a  small  lock  of  hair  between  the  fingers  near 
the  ear,  or  by  gently  tearing  paper.  They  are  heard 
in  the  earliest  stages  of  croupous  pneumonia,  before 
consolidation  has  been  established  {crepitatio  indux).  A 
similar  but  coarser  rale  may  be  heard  during  resolution 
of  pneumonia  [crepitatio  redux).  Crepitant  rales  are 
also  heard  in  catarrhal  pneumonia,  in  haemorrhagic 
infarction,  and  in  oedema  of  the  lung.  This  rale  is  by 
some  observers  regarded  as  an  ill  -  defined  pleural 
friction  sound.  Subcrepitani  rales — ^rather  coarser  than 
the  foregoing.  They  indicate  a  more  copious  or  fluid 
secretion   in   the  small  bronchi.     They  are  found  in 


RESPIRATORY  SYSTEM  59 

bronchitis,  inflammatory  consolidations  of  the  lungs, 
pulmonary  oedema,  hemorrhage,  or  hypostatic  conges- 
tion. Mucous  rales — a  larger  and  coarser  class  of  rale, 
originating  in  the  larger  bronchi  or  in  pulmonary 
cavities.  They  may  be  observed  in  bronchitis,  bronchi- 
ectasis, and  phthisis.  When  very  coarse,  they  are 
termed  gurgling  rales.  Consonating  rales — a  clear, 
crackling,  bright,  resonating  character  is  given  to  the 
rales  by  the  presence  of  solidified  lung,  through  which 
the  sounds  are  well  conducted  to  the  stethoscope. 
Metallic  rdles — an  extreme  degree  of  this  consonating 
quality,  often  heard  when  consolidation  surrounds  large 
open  bronchi  or  cavities.  Cavernous  rdles — in  which 
the  reverberating  quality  is  still  more  marked.  The 
amount  of  reverberation  will  depend  on  the  size  of 
the  cavity  and  the  condition  of  its  walls. 

In  many  cases  rales  are  only  produced  when  the 
patient  draws  a  deep  breath,  or  after  he  coughs.  On 
the  other  hand,  the  rales  sometimes  disappear  after 
coughing.  This  is  especially  likely  to  occur  in  cases  of 
mild  bronchial  catarrh,  but  may  be  an  evidence  of  early 
phthisis. 

(3)  Friction  Sound. — If  the  pleural  or  pericardial 
membranes  have  become  roughened  or  dried  with 
disease,  their  friction  during  respiration  (chiefly  inspi- 
ratory) may  be  enough  to  set  up  audible  vibrations. 
The  sounds  vary  from  a  faint  brushing  to  a  harsh,  grating, 
scraping,  or  creaking  noise.  The  fainter  varieties  re- 
semble, and  are  by  some  regarded  as,  crepitant  rales. 
A  fairly  accurate  idea  of  the  commoner  type  of  friction 
sound  is  gained  by  completely  covering  the  ear  with  the 
palm  of  the  hand,  and  gently  rubbing  the  back  of  that 
hand  with  the  finger  of  the  other  hand. 

A  friction  sound  restricted  to  the  pulmonary  region 


6o  SYSTEMATIC  CASE-TAKING 

indicates  pleurisy  (including  that  accompanying  pneu- 
monia or  phthisis)  and  tumour.  Precordial  friction 
usually  denotes  pericarditis,  but  may  be  caused  by 
pleurisy  affecting  the  edge  of  lung  which  overlies  the 
heart.  In  this  case  the  rub  might  be  heard  synchronous 
with  both  the  heart-beat  and  with  respiration,  and  is 
termed  pleurofericardial  friction. 

Friction  at  the  apex  of  a  lobe  often  indicates  phthisis. 
The  commoner  situations  are  the  infra-axillary,  mam- 
mary, and  infrascapular  regions,  where  it  may  denote 
simple  or  tubercular  pleurisy  or  pneumonia.  Friction 
sounds  disappear  when  the  pleural  surfaces  are  separ- 
ated by  effusion.  Reappearance  of  the  rub,  especially 
when  it  is  found  in  the  upper  portions  of  the  area  of 
dulness,  implies  the  removal  of  fluid  at  that  region. 
Adhesion  of  the  surfaces  or  resolution  of  the  pleurisy 
also  cause  the  rub  to  disappear. 

(4)  Bell  Sound.     See  above,  under  P^rcwss^'ow. 

(5)  Metallic  Tinkling,  a  faint  but  clear  musical 
note,  believed  to  be  due  to  the  falling  of  a  drop  of  fluid 
""rom  the  chest  wall  or  lung  into  the  serous  or  purulent 
exudation  of  a  pneumothorax.  A  somewhat  similar 
sound  is  produced  in  pulmonary  cavities  by  the  rever- 
berations added  to  mucous  rales  {amphoric  rdles). 

(6)  Succussion  Sounds. — ^When  air  and  fluid  are 
present  in  the  pleural  cavity,  they  give  rise  to  a  splashing 
sound  on  shaking  the  patient. 

There  are  a  few  adventitious  sounds  to  be  heard  over 
the  pulmonary  region  which  are  unconnected  with 
respiratory  affections — e.g.,  creaking  sounds  caused  by 
movements  of  the  scapula  upon  the  thorax  or  by  grating 
in  the  shoulder- joint ;  the  muscular  sound  produced 
by  contraction  of  the  chest  muscles  may  become  evident ; 
noises  arising  from  accidental  friction  of  the  stethoscope 


RESPIRATORY  SYSTEM  6i 

or  skin  may  simulate  friction  sounds.  Care  in  examin- 
ation, and  observation  of  the  effect  upon  these  sounds 
of  respiration,  will  in  most  cases  obviate  error. 

Examination  of  the  Sputum. — A  thorough  investiga- 
tion of  the  expectoration  has  to  be  made,  both  macro- 
and  microscopically.  The  colour  and  character  are 
to  be  noted,  whether  purulent,  mucous,  serous,  or  bloody. 
Microscopic  examination  discloses  the  constituents  of 
the  sputum,  both  in  its  cellular  and  non-cellular  elements 
— viz.,  red  and  white  blood  cells,  epithelial  cells,  elastic 
fibres,  crystals,  Curschmann's  spirals,  fragments  of  lung 
tissue,  actinomycosis. 

Micro-organisms  are  recognized  by  examination  of  a 
stained  film.  Other  methods,  such  as  inoculation  of 
animals  by  carefully  prepared  specimen  or  cultivation 
of  a  specimen,  are  carried  out  in  the  laboratory  when 
necessary.  A  smear  is  made  by  placing  a  small  morsel 
of  pus  from  the  sputum  between  two  cover-glasses,  which 
are  pressed  together,  then  drawn  apart ;  this  is  repeated 
several  times  till  the  film  is  quite  thin.  If  tubercle  bacilli 
are  suspected,  the  film  is  to  be  stained  by  the  Ziehl- 
Neelsen  method.  Further  examination  for  pneumo- 
coccus,  staphylococcus,  streptococcus,  etc.,  is  to  be 
made  by  Gram's  method  of  staining  (see  Appendix  II.). 


CHAPTER  V 

CIRCULATORY  SYSTEM 

Movements  of  the  chest  wall — Area  of  cardiac  dulness — Dis- 
placements of  the  apex-beat — Thrill — The  sounds  of  the 
heart — Adventitious  sounds — Murmurs — Friction  sounds — 
Examination  of  the  arteries,  veins,  and  capillaries. 

The  means  of  examination  described  in  discussing  the 
respiratory  system  are  also  to  be  employed  for  this 
system. 

Movements  of  the  Chest  Wall  due  to  circulation  are 
observed  by  inspection  and  palpation.  In  health  they_^ 
are  confined  to  a  spot  not  greater  than  an  inch  in 
diameter  in  the  fifth  left  interspace  just  inside  the  nipple 
line  and  outside  the  parasternal.  This  is  known  as 
the  apex-beat,  and  represents,  with  sufficient  accm'acy 
for  clinical  purposes,  the  situation  of  the  apex  of  the  heart 
in  the  thorax.  Diminution  of  this  movement  is  of  small 
diagnostic  importance,  as  its  disappearance  is  not  in- 
consistent with  health.  Weakening  of  its  force  may, 
however,  be  due  to  pericardial  effusion,  pulmonary 
emphysema,  feeble  ventricular  contraction  from  dila- 
tation, muscular  degeneration  of  the  heart,  or  from 
general  debility.  An  unduly  thick  chest  wall  is  a  common 
cause  (fat,  oedema).  Increase  of  the  force  and  extent 
of  the  apex-beat,  which  has  a  slow,  heaving  character, 
and  is  displaced  downwards  and  outwards,  indicates 
hypertrophy  of  the  left  ventricle.     Increased  force  and 

62 


CIRCULATORY  SYSTEM  63 

extent  of  the  impulse,  with  a  knocking  rather  than  a 
heaving  character,  but  without  displacement,  is  seen  in 
cases  of  palpitation  from  exertion,  from  emotions,  and 
as  an  effect  of  tea,  alcohol,  etc. 

Changes  in  the  position  and  extent  of  the  precordial 
pulsation  are  found  in  many  diseased  conditions,  and 
before  considering  them  it  will  be  convenient  to  examine 
the  region  of  the  heart  by  means  of  percussion. 

Area  of  Cardiac  Dulness. — The  portion  of  the  chest 
wall  in  contact  with  the  pericardial  sac  can  be  deter- 
mined, being  absolutely  dull  on  percussion.  It  is  known 
as  the  area  of  superficial  cardiac  dulness,  and  may  be 
defined  by  light  percussion  in  the  manner  already 
described  (Chapter  IV.).  Normally  it  extends  from  the 
level  of  the  fourth  costal  cartilage  above  down  to  the 
liver  dulness  ;  to  the  left  for  a  distance  of  about  3!  inches 
from  the  middle  line  to  a  point  in  the  fifth  interspace 
corresponding  to  the  apex-beat.  On  the  right,  the  area 
of  dulness  is  bounded  by  the  right  side-sternal  line. 
On  forcible  percussion,  a  comparative  dulness  is  found, 
extending  about  a  finger's  breadth  outside  the  above 
limits,  forming  the  area  of  deep  cardiac  dulness.  Altera- 
tions in  the  position  and  extent  of  this  area  and  of  the 
pulsations  of  the  heart  have  to  be  noted. 

Displacements  of  the  Apex-Beat  may  be  due  to  disease 
of  the  heart  itself,  of  the  lungs,  pleurae,  mediastinum, 
abdominal  organs,  etc.  If  downward  and  to  the  left, 
it  is  usually  caused  by  hypertrophy  and  dilatation  of 
the  heart,  particularly  of  the  left  ventricle.  Upwards 
and  to  the  left :  contractions  of  the  left  lung  and  pleura 
{fibroid  phthisis,  removed  pleural  exudations,  with  re- 
traction of  the  lung)  pull  the  heart  across,  while  it  may 
h^  pushed  in  the  same  direction  by  right  pleural  effusions, 
by  mediastinal  tumours,  or  by  abdominal  pressure.  With 


64  SYSTEMATIC  CASE-TAKING 

the  exception  of  pericardial  effusion,  this  displacement 
is  rarely  produced  by  cardiac  affections.  Directly  out- 
ward to  the  left :  by  the  causes  last  mentioned ;  by 
dilatation  of  the  right  ventricle.  Directly  downward : 
aneurism  of  the  arch  of  the  aorta,  mediastinal  tumours, 
emphysema  of  the  lungs.  To  the  right :  left  pleural 
effusion,  tumour  of  left  lung,  contraction  of  right  lung, 
dextrocardia.  Changes  of  posture  only  slightly  modify 
the  position  and  force  of  the  apex-beat. 

Hypertrophy  of  the  right  ventricle  causes  pulsation 
in  the  lower  region  near  the  sternum.  Retraction  of 
the  lung  from  phthisis  may  make  evident  the  pulsation 
of  the  heart.  In  the  left  second  intercostal  space  the 
pulsation  of  the  pulmonary  artery  may  be  visible  near 
the  sternum  ;  on  the  right  side  a  corresponding  pulsation 
may  be  due  to  the  aorta.  Pulsation  in  the  episteiiial 
notch,  if  very  forcible,  may  result  from  dilatation  or 
aneurism  of  the  aorta,  but  may  be  an  unusually  active 
innominate  artery. 

Pulsation  behind  the  upper  half  of  the  sternum  or 
immediately  to  either  side  is  seen  in  aneurism  of  the 
aorta.  Epigastric  pulsation,  if  systolic,  may  be  from 
a  strongly-acting  right  ventricle  or  a  displaced  apex-beat ; 
or  the  normal  heart  movement  may  be  transmitted  to 
the  surface  at  this  spot  through  the  liver  or  tumour  in 
the  epigastrium.  It  is  often  due  to  the  so-called 
irritable  aorta,  observed  in  nervous  subjects.  Rarely 
the  epigastric  pulsation  is  due  to  aneurism  of  the 
abdominal  aorta.  In  this  position  a  pulsating  liver 
may  be  observed  in  cases  of  serious  incompetency  of 
the  tricuspid  orifice. 

Instead  of  pulsation  a  retraction  of  the  thorax  at 
places  may  occur.  This  is  seen  in  the  lower  inter- 
costal spaces  behind,  as  the  result  of  pericardial  ad- 


CIRCULATORY  SYSTEM  65 

hesions  involving  the  diaphragm  and  lateral  chest  walls 
(Broadbent's  sign).  It  may  also  be  observed  in  the 
precordial  region  from  the  same  cause,  and  is  seen 
commonly  in  the  epigastrium  with  the  contraction  of 
the  right  ventricle. 

The  extent  of  the  area  of  cardiac  dulness  varies  greatly 
in  disease.  It  is  diminished  or  abolished  in  emphy- 
sema ;  it  is  increased  in  dilatation  and  hypertrophy  of 
the  heart,  in  pericardial  effusion,  and  in  retraction  of 
the  lung.  In  pericardial  effusion  the  shape  of  the  dull 
area  differs  from  that  due  to  heart  enlargement.  The 
chief  increase  is  laterally,  the  right  border  of  the  dull 
area  sloping  outwards  toward  the  right,  thus  forming  a 
pyramidal-shaped  area  of  dulness,  with  its  base  on  the 
diaphragm.  The  area  of  cardiac  dulness  may  also  be 
apparently  enlarged  by  the  presence  of  mediastinal 
tumour  or  aneurism. 

Pulsations  in  the  neck  may  be  more  obvious  than 
normal.  Excessive  arterial  movements  are  seen  in 
aortic  incompetence  and  in  a  strongly  -  acting  heart 
without  disease.  The  venous  pulse,  when  well  marked, 
usually  indicates  dilatation  of  the  right  side  of  the 
heart. 

Thrill. — Vibrations  originating  at  one  of  the  orifices 
may  in  some  cases  be  felt  as  a  quivering  movement. 
It  is  most  likely  to  be  felt  in  obstruction  of  an  orifice  ; 
thus  a  thrill  is  most  commonly  felt  at  the  apex  of  the 
heart,  occurring  in  the  period  of  auricular  contraction — 
i.e.,  presystolic  —  and  caused  by  mitral  stenosis.  A 
systolic  thrill  at  the  base  indicates  in  most  cases  con- 
traction or  roughening  of  the  aortic  orifice.  Thrills 
due  to  regurgitation  through  the  aortic  or  mitral  valves 
are  occasionally  met  with,  but  are  of  rarer  occurrence. 
In  the  larger  arteries  thrills  may  sometimes  be  felt  as 

5 


66  SYSTEMATIC  CASE-TAKING 

the  result  of  constriction  from  some  cause  at  a  more 
proximal  point. 

The  Heart  Sounds. — ^The  patient  is  to  be  examined 
with  the  stethoscope,  both  in  the  upright  and  in  the 
recumbent  position.  Any  departure  from  the  quality 
of  the  normal  sounds  has  to  be  noted. 

The  sounds  are  intensified  by  increased  activity  of 
the  heart  from  bodily  exertion,  emotional  excitement, 
Graves'  disease,  cardiac  hypertrophy,  Bright's  disease, 
and  sometimes  from  valvular  heart  disease.  In  other 
and  less  common  instances  increased  loudness  is  due  to 
improved  conduction  of  sound,  as  may  occur  in  pul- 
monary consolidation,  in  pneumothorax,  in  cavities  of 
the  lung,  and  in  retraction  of  the  lung  from  the  pre- 
cordial area. 

The  second  sound  is  frequently  accentuated  ;  it  most 
commonly  occurs  in  mitral  disease,  when  the  right 
ventricle  is  acting  forcibly,  and  it  is  best  heard  over 
the  second  left  costal  cartilage.  In  Bright's  disease, 
arterio-sclerosis,  and  aortic  aneurism,  the  second  sound 
is  most  accentuated  near  the  second  right  costal  car- 
tilage, owing  to  increased  tension  in  the  aorta. 

Increased  loudness  of  the  first  sound  is  heard  at  the 
apex  in  cases  of  mitral  stenosis ;  here  the  accentuated 
first  sound  follows  an  immediately  preceding  murmur. 

The  normal  heart  sounds  are  weakened  by  all  con- 
ditions which  decrease  the  power  of  ventricular  con- 
traction, or  which  reduce  tension  in  the  aorta  and 
pulmonary  artery — e.g.,  debility  following  acute  disease, 
collapse,  failure  of  the  heart  from  degeneration  of  its 
muscle  fibres.  The  sounds  are  also  enfeebled  by  im- 
perfect conduction  of  the  sounds — e.g.,  a  thick  chest 
wall,  pericardial  effusion,  pulmonary  emphysema.  In- 
competency of  the  aortic  valves,  owing  to  their  imperfect 


CIRCULATORY  SYSTEM  67 

closure,  causes  weakness  or  loss  of  the  second  sound, 
which  here  may  be  replaced  by  a  murmur.  Weakening 
of  the  loud  first  sound  of  mitral  stenosis  or  of  the  in- 
tensified second  sound  of  mitral  regurgitation  or  stenosis 
indicates  failure  of  the  left  and  right  ventricle  respec- 
tively. Tricuspid  incompetence  (usually  from  dilata- 
tion of  the  right  ventricle)  reduces  tension  in  the  pul- 
monary artery,  with  consequent  weakening  of  the 
pulmonic  second  sound. 

Irregularities  in  the  rhythm  of  the  sounds  are  to  be 
noted.  Pendulum  rhythm  is  an  even  series  of  sounds, 
such  as  might  be  produced  by  a  pendulum  swinging 
truly,  the  normal  rhythm  being  that  of  a  badly-hung 
pendulmn.  It  is  found  in  some  cases  of  high  arterial 
tension,  and  is  probably  due  to  prolongation  of  the 
closure-time  of  the  heart,  whereby  the  second  sound 
is  delayed.  Embryocardia,  or  fcetal-heart  rhythm,  is 
similar  but  quicker,  and  is  usually  a  bad  sign.  It 
occurs  in  heart  exhaustion,  as  in  fevers,  in  diphtheritic 
or  other  paralyses  affecting  the  heart,  and  in  the  terminal 
stages  of  heart  disease. 

Prolongation  of  the  first  sound  usually  means  hyper- 
trophy of  the  ventricles  ;  if  shortened,  dilatation. 

Reduplication  of  the  Heart  Sounds. — ^Doubling  of  the 
second  sound  results  from  want  of  synchronism  in  the 
closure  of  the  semilunar  valves.  Any  condition  which 
hastens  the  diastolic  fall  of  pressure  in  the  ventricle 
will  hasten  the  second  sound.  In  mitral  stenosis  the 
diastolic  fall  in  tension  in  the  left  ventricle  is  hastened 
by  the  poor  supply  of  blood  from  the  left  auricle,  so 
that  the  aortic  cusps  close  sooner  than  usual  and  before 
the  pulmonary.  In  mitral  regurgitation,  on  the  con- 
trary, the  distended  left  auricle  will  rapidly  fill  the  left 
ventricle,  and  so  delay  the  fall  in  left  intraventricular 


68  SYSTEMATIC  CASE-TAKING 

tension  ;  hence  the  aortic  cusps  are  the  last  to  close. 
Another  and  more  commonly  accepted  explanation  of 
the  doubled  second  sound  is  that  the  increased  tension 
in  the  pulmonary  circulation  in  mitral  disease  causes 
the  pulmonary  cusps  to  close  before  the  aortic  ;  normally, 
however,  the  aortic  tension  is  much  higher  than  the 
pulmonary,  and  yet  the  two  orifices  are  simultaneously 
closed. 

The  second  sound  may  be  apparently  reduplicated  by 
the  presence  of  a  murmur  in  the  early  part  of  the 
diastole,  due  to  mitral  stenosis  or  to  aortic  regurgitation 
transmitted  to  the  apex. 

Reduplication  of  the  first  sound  is  usually  in  reality 
an  indistinct  presystolic  or  late  systolic  murmur^    " 

Gallop  Rhythm. — ^There  are  three  sounds  with  each 
beat,  the  third  being  usually  accentuated.  This  is 
often  observed  when  the  heart  muscle  is  failing,  as  in 
the  feeble  heart  of  broken-down  compensation,  of  fatty 
degeneration,  or  of  advanced  Bright's  disease.  It  may 
also  occur  with  the  excited  cardiac  action  of  emotions, 
of  excessive  exercise,  or  of  exophthalmic  goitre.  The 
cause  is  uncertain,  the  first  of  the  three  elements  being, 
perhaps,  an  abnormal  sound  or  murmur,  due  to  passive 
tension  of  the  weakened  ventricle  or  to  auricular  con- 
traction. 

Altered  Quality  of  Sounds. — A  metallic  or  ringing 
quality  is  heard  when  the  heart  is  acting  forcibly  from 
any  cause,  or  in  the  condition  known  as  "  arterio- 
sclerosis," where  the  vessels  and  valve  cusps  have  be- 
come hardened  through  disease.  The  proximity  of 
resoimding  air  cavities  may  add  a  metallic  or  reverber- 
ating quality  to  the  normal  heart  sounds. 

Slight  impurity  of  the  sounds  may  be  due  to  some 
unusual  degree  of  rigidity  or  tension  of  the  cardiac 


CIRCULATORY  SYSTEM  69 

tissues,  without  lesion  of  the  valves,  but  in  some  cases 
such  impurities  can  be  changed  into  a  definite  murmur 
by  increasing  the  force  of  the  heart's  action  with  exercise. 

Adventitious  Sounds. — Abnormal  sounds  produced  by 
the  organs  of  circulation  in  the  thorax  are — (i)  Endo- 
cardial and  vascular  murmurs  ;  (2)  exocardial  sounds. 

I.  Endocardial  Murmurs,— The  term  "murmur"  is 
usually  restricted  to  sounds  produced  by  a  blood  current 
set  in  vibration  by  some  abnormal  condition  of  the  blood 
channels.  Normally  the  blood  current  is  noiseless,  but 
in  disease  the  so-called  fluid  vein  is  often  produced, 
usually  by  the  sudden  alteration  in  the  sectional  area 
of  the  channel,  audible  vibrations  being  thus  produced 
in  the  fluid.  Similar  vibrations  occur  as  a  result  of  the 
blood  stream  passing  over  roughened  or  irregular  surfaces, 
even  when  the  lumen  is  not  altered  in  size.  Some 
authors  include  in  the  term  "  murmur  "  friction  sounds 
caused  by  the  rubbing  of  roughened  pericardial  surfaces, 
but  it  seems  better  to  restrict  the  use  of  the  word  to 
those  noises  produced  by  the  blood  current  alone. 

In  some  cases  they  do  not  depend  upon  anatomical 
changes  in  the  heart,  and  are  termed  ''  functional," 
*'haemic,"  or  ''accidental."  The  following  points  are 
in  favour  of  a  murmur  being  accidental  :  A  soft,  blowdng 
systolic  murmur,  best  heard  near  the  second  left  costal 
cartilage  ;  anaemia  or  fever  may  be  present ;  there  may 
be  a  venous  hum ;  other  evidence  of  cardiac  affection 
may  be  wanting — e.g.,  no  history  of  rheumatism,  no 
enlargement  of  the  heart,  no  accentuation  of  the  second 
sound,  no  changes  in  the  pulse,  nor  signs  of  impaired 
circulation  in  the  various  organs  and  tissues  of  the  body. 

In  the  heart  the  lesion  causing  the  murmur  is  almost 
invariably  at  one  of  the  orifices,  and  consists  in  either 
a  leaking  (incompetence),  a  narrowing  (stenosis),  or  a 


70  SYSTEMATIC  CASE-TAKING     • 

roughening  of  the  orifice  in  question.  Incompetence  is 
produced  either  by  damage  to  the  protecting  cusps  of  the 
orifice  (usually  by  endocarditis)  or  by  dilatation  of  the 
chamber,  whereby  proper  apposition  of  the  cusps  is  pre- 
vented. Dilatation  commonly  occurs  as  a  result  of  de- 
generative changes  in  the  heart  muscle.  Stenosis  is 
caused  by  cicatricial  contraction  or  by  adhesion  of  valve 
cusps  following  inflammation. 

In  studying  a  precordial  murmur,  one  must  determine 
(i)  its  point  of  maximum  intensity  ;  (2)  its  time ;  (3)  the 
direction  in  which  the  murmur  seems  best  propagated ; 
and  (4)  the  character  or  quality  of  the  murmur. 

(i)  Point  of  Maximum  Intensity. — -One  can  ilsually 
distinguish  a  spot  on  the  front  of  the  chest  where  a  mur- 
mur is  more  distinctly  heard  than  elsewhere.  This  point 
does  not  necessarily  correspond  to  the  position  of  the 
orifice  from  which  the  sound  emanates,  but  is  determined 
by  the  varying  conditions  of  the  underlying  structures 
as  to  their  sound-conducting  capacity. 

Murmurs  best  heard  near  the  apex-beat  [mitral  area) 
nearly  always  originate  at  the  mitral  orifice.  If  at  the 
lower  end  of  the  sternum  or  close  to  either  side  of  its 
lower  part  (tricuspid  area),  the  tricuspid  is  probably  at 
fault.  The  immediate  vicinity  of  the  second  right  costal 
cartilage,  known  as  the  aortic  area,  is  the  situation  where 
murmurs  produced  at  the  aortic  orifice  are  often  best 
heard,  though  diastolic  murmurs  of  aortic  origin  are 
often  heard  better  down  the  sternum  and  to  the  left 
[secondary  aortic  area).  At  the  pulmonary  area,  as  the 
neighbourhood  of  the  second  left  costal  cartilage  is  termed, 
murmurs  generated  at  the  pulmonary  orifice  and  in  the 
pulmonary  artery  are  best  heard. 

If  more  than  one  point  of  maximum  intensity  can 
be  demonstrated,  more  than  one  lesion  is  present. 


CIRCULATORY  SYSTEM  71 

(2)  Time  of  the  Murmur. — Ascertain  at  what  precise 
period  of  the  cardiac  cycle  the  murmur  occurs.  The 
moment  of  ventricular  contraction  may  be  identified 
by  placing  the  finger  over  the  apex  or  on  the  carotid 
artery,  or  by  recognizing  the  first  sound  of  the  heart  by 
the  stethoscope.  Those  murmurs  which  occur  simul- 
taneously with  the  ventricular  contraction  are  called 
systolic  murmurs.  Those  occurring  immediately  before 
the  ventricle  contracts  are  presystolic  murmurs,  and  the 
term  diastolic  applies  to  all  murmurs  occurring  after  the 
second  sound  and  before  the  first  (including  the  pre- 
systolic murmur). 

Systolic  Murmurs  originating  in  one  of  the  four  orifices 
of  the  ventricles — i.e.,  excluding  accidental  murmurs — 
are  obviously  due  to  the  passing  of  blood  from  the 
ventricles,  which  are  at  that  moment  in  the  act  of  con- 
tracting. If  we  have  reason  to  believe  that  the  lesion 
is  at  the  mitral  or  tricuspid  orifices,  it  must  be  of  the 
nature  of  a  leakage  permitting  the  blood  to  leave  the 
ventricle  in  a  backward  direction  (regurgitation).  If,  on 
the  other  hand,  the  aortic  or  pulmonary  orifice  is  at 
fault,  it  is  caused  by  the  blood  passing  onward  in  the 
natural  direction,  and  is  termed  an  onward  or  obstructive 
murmur. 

Systolic  murmurs  heard  best  at  the  apex  (mitral  area) 
are  therefore  due  to  mitral  incompetence.  At  the 
tricuspid  area  a  similar  murmur  indicates  leakage  through 
the  tricuspid  orifice,  almost  invariably  the  result  of 
dilatation  of  the  right  ventricle.  At  the  base  systolic 
murmurs  are  less  definite  in  diagnostic  significance.  On 
the  left  side,  at  the  pulmonary  region,  as  already  stated, 
they  are  commonly  functional  or  accidental  in  character. 
At  the  aortic  area  over  the  right  second  costal  cartilage 
systolic  murmurs  indicate  (a)  roughening  or  irregularity 


72  SYSTEMATIC  CASE-TAKING 

of  the  inner  surface  of  the  aorta  or  the  aortic  orifice  ; 
(h)  dilatation  of  the  aorta  ;  or  (c)  contraction  (stenosis) 
of  the  aortic  orifice. 

A  systolic  murmur  at  the  base  may  in  rare  instances 
be  due  to  aortic  aneurism,  congenital  heart  defects,  or 
the  pressure  of  a  tumour  upon  the  large  vessels  in  the 
mediastinum. 

In  some  cases  of  mitral  incompetence  the  valve  only 
leaks  towards  the  end  of  ventricular  contraction,  owing 
to  some  anomaly  of  the  papillary  muscles.  Here  the 
murmur  occurs  in  the  late  portion  of  the  diastole,  and  is 
known  as  a  late  systolic  or  prediastolic  murmur. 

Diastolic  Murmurs — i.e.,  those  occurring  at  any  period 
of  the  cardiac  cycle,  except  that  of  ventricular  con- 
traction— are  produced  by  the  entrance  into  the  ven- 
tricles of  blood  through  one  or  other  of  the  orifices. 
When  best  heard  at  the  aortic  or  secondary  aortic,  or 
pulmonary  area,  a  murmur  replacing  or  accompanying 
the  second  sound  is  due  to  reflux  through  a  leaking 
aortic  valve,  and  very  rarely  to  regurgitation  througl) 
the  pulmonary  orifice. 

A  murmur  occurring  a  little  later  in  the  period  of  rest 
— the  so-called  early  diastolic  murmur — may  be  heard  at 
the  apex  in  some  cases  of  mitral  stenosis.  It  is  heard  at 
the  moment  when  the  relaxed  ventricles  are  being  filled 
by  a  stream  from  the  auricles.  Owing  to  constriction 
of  the  mitral  orifice,  the  tension  is  raised  in  the  left 
auricle,  so  that  the  current  through  the  orifice  may  be 
brisk  enough  to  produce  a  murmur.  This  occurs  soon 
after  the  closure  of  the  semilunar  valves,  and  before 
the  contraction  of  the  auricles.  A  murmur  heard 
immediately  before  the  first  sound  [presystolic  murmur) 
is  a  more  common  and  characteristic  result  of  mitral 
stenosis. 


CIRCULATORY  SYSTEM  73 

Another  diastolic  murmur  best  heard  at  the  apex  is 
that  known  as  Flint's  murmur.  It  is  observed  in  cases 
where  the  aortic  orifice  is  incompetent  and  the  left 
ventricle  is  dilated.  The  exact  mode  of  its  production 
is  uncertain,  but  it  is  probably  due  to  vibrations  set  in 
motion  by  the  reflux  current  through  the  aortic  orifice 
striking  the  anterior  cusp  of  the  mitral  valve.  It  is 
distinguished  from  the  murmur  due  to  mitral  stenosis 
by  the  presence  of  signs  of  aortic  disease,  and  by  the 
absence  of  accentuation  of  the  second  sound. 

A  rare  cause  of  presystolic  murmur  is  tricuspid 
stenosis,  which  resembles  that  due  to  mitral  stenosis, 
but  is  best  heard  in  the  tricuspid  area. 

(3)  Transmission  of  the  Munmir. — When  the  point  of 
maximum  intensity  of  a  murmur  is  determined,  the  bell 
of  the  stethoscope  should  be  moved  along  lines  radi- 
ating from  the  spot  where  it  is  best  heard.  It  is  often 
found  that  the  murmur  can  be  heard  farthest  along  one 
or  other  of  these  radiating  lines.  This  line  is  termed 
the  "  line  of  transmission  or  direction  "  of  the  mur- 
mur, and  is  influenced  not  onl}^  by  the  conductivity 
of  the  tissues,  but  also  by  the  direction  of  the  blood 
current. 

The  apical  systolic  murmur  of  mitral  incompetence 
is  directed  towards  the  left  axilla,  and  may  often  be 
heard  below  the  left  scapula.  A  similar  murmur  re- 
sulting from  tricuspid  incompetence  is  better  heard 
towards  and  to  the  right  of  the  sternum.  The  diastolic 
murmur  resulting  from  aortic  regurgitation  is  trans- 
mitted best  downward  toward  the  ensiform  cartilage. 

The  systolic  murmur  of  aortic  disease  is  usualh^ 
transmitted  upward  into  the  vessels  of  the  neck,  and 
may  be  extensively  transmitted  in  all  directions. 

The  presystolic  murmur  of  mitral  stenosis  is   trans- 


74  SYSTEMATIC  CASE-TAKING 

mitted,  if  at  all,  towards  the  sternum  ;  but  is  usually 
fairly  localized. 

(4)  Character  of  the  Murmur. — Loudness  or  faintness 
does  not  constitute  any  measure  of  the  amount  of  injury 
present,  as  a  serious  lesion  may  only  produce  a  feeble 
murmur,  and  vice  versa.  If  the  murmur  be  loud,  it  may 
be  assumed  that  the  blood  current  through  the  affected 
orifice  is  at  any  rate  energetic.  In  cases  of  mitral 
stenosis,  the  greater  the  contraction  the  louder  the 
murmur,  as  a  rule  ;  but  in  mitral  regurgitation  an  un- 
mportant  lesion  may  give  rise  to  a  much  louder  murmur 
than  a  serious  leaking. 

Generally  speaking,  obstructive  or  onward  murmurs 
are  harsh,  while  the  murmurs  of  regurgitation  are  often 
soft  and  blowing.  The  harsh  murmur  of  mitral  stenosis 
has  also  the  quality  of  ingravescence — that  is,  it  grows 
louder  as  it  progresses,  and  ends  suddenly  in  the  first 
sound. 

Certain  changes  in  the  character  of  a  murmur  may  be 
dependent  upon  circumstances  unconnected  with  the 
circulatory  organs.  An  increased  loudness  or  resonating 
quality  may  be  the  result  of  consolidation  of  the  lung, 
a  pulmonary  cavity,  or  other  source  of  improved  con- 
duction of  the  murmur. 

Vascular  Murmurs. — See  below. 

2.  Exocardial  Sounds. — ^The  following  sounds,  not 
produced  in  the  heart  or  bloodvessels,  but  caused  by 
the  heart's  action,  are  to  be  noted  : 

(i)  Pericardial  Friction  Sounds,  resulting  from  the 
rubbing  together  of  roughened  pericardial  surfaces, 
usually  heard  over  a  very  limited  area  of  the  chest,  but 
if  loud  they  are  more  extensively  distributed.  They 
have  a  to-and-fro  rhythm,  independent  of  the  normal 
heart  sounds,  and  are  usually  superficial — that  is,  the 


CIRCULATORY  SYSTEM  75 

sounds  seem  to  be  immediately  below  the  bell  of  the 
stethoscope.  They  may  be  soft  or  harsh,  according  to 
the  conditions  of  the  surfaces  involved. 

(2)  Pleuro-Pericardial  Friction — that  is,  the  rubbing 
of  roughened  surfaces  external  to  the  pericardial  sac, 
synchronously  with  the  heart-beat. 

(3)  Pericardial  Splashing. — A  splashing  sound  syn- 
chronous with  the  heart-beat  may  indicate  the  presence 
of  both  air  and  liquid  in  the  pericardial  sac — a  rare 
occurrence.  Similar  sounds  may  occasionally  be  heard 
when  the  heart's  movements  cause  agitation  in  adjacent 
cavities  containing  air  and  liquid — viz.,  pyopneumo- 
thorax, large  pulmonary  cavities,  distended  stomach. 

(4)  Cardio-Pulmonary  and  Other  Sounds. — Sounds  re- 
sembling pleuro-pericardial  rubs  may  arise  from  the 
audible  expulsion  of  air  from  an  emphysematous, 
cedematous,  or  congested  margin  of  lung  overlapping 
the  heart ;  from  the  presence  of  surgical  emphysema  in 
the  mediastinum  ;  from  diaphragmatic  pleurisy  ;  or 
from  subdiaphragmatic  inflammation.  A  consideration 
of  the  general  symptoms  and  condition  will  usually 
distinguish  these  different  affections. 

Examination  of  the  Bloodvessels — Arteries. — In  Chap- 
ter II.  are  some  general  considerations  regarding  the 
pulse.  As  a  rule,  the  pulsations  of  the  arteries  cannot 
be  seen,  but  in  many  cases  they  can  be  easily  felt. 
When  visible,  the  pulsations  are  usually  more  ample 
than  those  in  health,  the  excess  being  due  to  (a)  excited 
circulation,  as  in  emotions,  hysteria,  exercise,  exoph- 
thalmic goitre  ;  (&)  the  pulsus  celer,  or  bounding  pulse, 
seen  typically  in  aortic  incompetence  and,  to  a  less 
degree,  in  fevers ;  (c)  aneurismal  dilatation  of  the 
vessels — a  rare  cause  of  visible  pulsation. 

In  some  cases  the  larger  arteries  should  be  auscul- 


76  SYSTEMATIC  CASE-TAKING 

tated  ;  the  two  heart  sounds  can  usually  be  heard  in  the 
large  vessels.  By  pressure  of  the  stethoscope  over  a 
large  artery,  a  systolic  bruit  is  normally  elicited.  The 
systolic  and  diastolic  murmurs  of  aortic  disease  are  easily 
heard  in  the  carotid,  and  often  in  the  subclavian.  Some- 
times they  are  heard  in  the  femoral.  Place  the  stetho- 
scope gently  over  the  femoral  artery  without  pressure, 
and  either  one  or  two  sounds  resembling  the  normal 
heart  sounds  may  be  heard.  A  little  pressure  now  gives 
the  usual  systolic  arterial  murmur ;  press  stUl  more, 
and,  with  careful  graduation  of  the  pressure,  one  often 
succeeds  in  hearing  not  only  a  systolic,  but  also  a  diastolic 
murmur,  which  is  not  heard  in  health.  This  is  known  as 
Duroziez's  double  murmur. 

The  arteries  in  connection  with  the  enlarged  thyroid 
gland  in  cases  of  exophthalmic  goitre  often  give  out  a 
systolic  murmur  without  pressure. 

Veins. — Varicose  enlargement  of  the  veins  is  usually 
a  surgical  affection.  An  unusually  distended  condition 
of  the  veins  is,  however,  in  some  medical  cases,  of  diag- 
nostic importance.  In  the  head,  neck,  and^upper  part 
of  the  thorax,  enlarged  veins  frequently  indicate  some 
serious  obstruction  in  the  course  of  the  superior  vena 
cava,  such  as  mediastinal  tumour  or  aneurism,  or 
severe  disease  of  the  right  heart.  Enlargement  of  the 
veins  on  the  lower  part  of  the  thorax  and  over  the 
abdomen  are  usually  due  to  disease  of  the  abdominal 
organs  (see  Chapter  VII.). 

Pulsation  of  the  veins  in  the  neck  is  sometimes  found 
in  health,  but  is  usually  the  result  of  some  disturbed 
action  of  the  right  side  of  the  heart.  The  patient  should 
be  in  the  recumbent  position,  if  possible,  and  an  effort 
must  be  made  to  place  accurately  the  venous  movements 
in   their  proper  position   in   the  cardiac   cycle.     It   is 


CIRCULATORY  SYSTEM  77 

usually  impossible  to  do  this  satisfactorily  by  the  unaided 
eye,  and  a  graphic  record  of  the  movements  is  necessary 
if  fuU  advantage  is  to  be  taken  of  the  information 
afforded  by  pulsating  veins.  This  may  be  obtained  by 
means  of  recording  tambours,  and  Mackenzie's  ink  poly- 
graph supplies  all  the  data  required  in  clinical  ex- 
amination. 

The  pulsations  thus  recorded  may  be  a  combination 
of  venous  and  arterial  pulses,  but  careful  study  of  these 
tracings  and  of  those  obtained  from  the  apex-beat, 
radial  artery,  etc.,  enables  one  to  analyze  in  many  cases 
the  constituent  factors  producing  the  movements.  By 
this  means  the  condition  of  the  heart  muscle  can  be 
investigated,  and  much  has  been  thus  learned  of  the 
nature  of  disturbed  rhythm. 

Auscultation  of  the  veins  of  the  neck  in  cases  of 
anaemia  discloses  a  continuous  murmur,  often  loud, 
snoring,  or  musical  in  quality,  known  as  the  venous 
hum,  bruit  de  diahle,  or  Nun's  murmur. 

Capillaries. — Excessive  pulsation  of  the  arteries  trans- 
mitted to  the  capillaries  (almost  always  an  indication 
of  aortic  regurgitation)  is  shown  by  rhythmical  paling 
and  deepening  in  the  colour  of  the  skin.  This  is  best 
seen  on  causing  red  patches  to  appear  by  rubbing  the 
skin.  Similar  capillary  pulsation  may  be  seen  in  the 
finger-nails. 


CHAPTER  VI 
BLOOD 

Blood  examination — The  glandular  system. 

Blood  Examination. — In  certain  cases  an  examination 
of  the  blood  is  to  be  made.  The  following  is  a  brief 
description  of  the  methods  recommended  as  suitable 
for  clinical  purposes : 

The  chief  points  to  be  investigated  are — (i)  the 
number  of  red  and  white  corpuscles  per  cubic  milli- 
metre of  the  blood  ;  (2)  the  percentage  of  haemoglobin 
present  as  compared  with  normal  blood ;  (3)  the 
character  of  the  red  and  white  cells  and  their  propor- 
tionate count ;  (4)  WidaV^  reaction;  (5)  Wassermann's 
reaction. 

1.  Enumeration  of  the  Red  Cells. — In  calculating  the 
percentage  of  red  cells  present,  5,000,000  per  cubic  milli- 
metre may  be  taken  as  the  normal  count.  Thoma's  or 
Gowers'  haemocytometer  gives  reliable  results.  A  known 
quantity  of  diluted  blood  is  placed  by  means  of  a  suit- 
able pipette  on  a  microscope  slide  divided  by  engraved 
lines  into  squares  2V  millimetre  across.  The  number  of 
red  or  white  cells  lying  in  a  given  number  of  squares 
is  counted,  and  the  quantity  of  blood  which  supplied 
the  cells  can  then  be  calculated  without  difficulty. 

2.  The  haemoglobin  value  of  the  blood  may  be  de- 

78 


BLOOD  79 

termined  by  the  haemocytometer  of  Gowers,  Sahli,  or 
Haldane.  The  estimation  of  the  percentage  of  haemo- 
globin is  made  by  comparing  the  colour  of  diluted  blood 
with  a  standard  colour. 

Colour  Index. — ^A  convenient  means  of  expressing  the 
relation  of  the  percentage  of  haemoglobin  to  that  of  the 
red  cells  in  the  blood  is  by  determining  the  "  colour 
index."  Thus,  a  normal  specimen  of  blood  has  lOO  per 
cent,  of  both  haemoglobin  and  red  cells,  and  is  expressed 

as  -— -  =  I.  Suppose  the  blood  showed  60  per  cent,  haemo- 
globin and  80  per  cent,  red  cells,  the  colour  index  would 
be  K-  =  0'75.  Should  the  haemoglobin  be,  say,  50  per 
cent,  and  the  red  cells  40  per  cent.,  the  colour  index 
would  be  ^  =  1-25.     In  the  diagnosis  of  different  types 

of  anaemia  this  relationship  is  of  help.  Thus,  the  colour 
index  of  pernicious  anaemia  is  high,  being  usually  i  or 
more  ;  while  in  chlorosis  it  is  invariably  below  unity,  and 
often  as  low  as  0*5.  Other  secondary  anaemias  nearly 
always  show  a  colour  index  below  i. 

3.  A  film  is  to  be  prepared  and  stained.  A  small  drop 
of  blood  taken  from  the  finger  or  lobe  of  the  ear  is  spread 
thinly  on  the  cover-glass  by  means  of  another  glass  or 
piece  of  cigarette-paper.  A  little  practice  enables  one 
to  spread  such  a  film  sufficiently  thin  and  even.  It  is 
then  treated  with  a  staining  fluid,  of  which  Leishman's 
offers  many  advantages. 

On  examining  with  a  microscope  a  normal  blood  film 
stained  in  this  manner,  the  red  cells  are  seen  coloured  a 
pinkish-red,  their  discs  for  the  most  part  lying  flat  on 
the  surface  of  the  glass,  and  measuring  7  />t  to  8  /x  in 
diameter  (ft=a?jTF^  inch).    The  white  cells  are  found 


. .     7<^  psi 

cent. 

••     23 

)> 

..       3 

}} 

2 

»> 

2 

80  SYSTEMATIC  CASE-TAKING 

in  greater  variety,  the  following  being  an  average  pro- 
portionate count : 

Polymorphonuclear  leucocytes 
Small  lymphocytes  . . 
Large  mononuclear  leucocytes 
Transitional  leucocytes 
Eosinophile  leucocytes 

In  diseased  conditions  changes  are  found  in  both  red 
and  white  cells — viz.  :  Poikilocytes :  red  cells  distorted 
in  shape.  Megalo-  and  Microcyfes  :  cells  unusually  large 
and  unusually  small,  but  otherwise  resembling  the 
normal  red  cells.  Polychromatophilia  :  red  cells  which 
stain  a  bluish-red  or  violet  with  Leishman's  stain. 
Basophile  Granulation :  cells  with  granules  which  stain 
well  with  basic  stains,  and  are  therefore  blue  with  all 
staining  methods.  Nucleated  Red  Cells  occur  in  two 
forms — normoblasts,  the  size  of  a  normal  red  cell,  with 
a  deeply  staining  homogeneous  nucleus  ;  and  megalo- 
hlasts,  red  cells  of  a  larger  size  than  the  normal.  Various 
nucleated  red  cells,  transitional  between  normoblasts 
and  megaloblasts,  may  be  found.  Neutrophile  Myelo- 
cytes :  large  granular  cells  with  a  single  divided  nucleus. 
These  constitute  the  majority  of  the  cells  of  the  bone- 
marrow,  but  do  not  normally  find  their  way  into  the 
general  circulation.  Eosinophile  Myelocytes  have  a 
somewhat  smaller  nucleus  than  the  neutrophile  myelo- 
cytes. They  occur  normally  in  the  bone-marrow,  but 
not  in  the  general  circulation.  Non-Granular  Marrow 
Cells :  large  cells  with  a  homogeneous  protoplasm  and 
faintly  staining  nucleus — probably  transitional  forms  of 
myelocytes. 

In  any  severe  anaemia  poikilocytes,  megalocytes, 
and  microcytes,  can  usually  be  recognized,  and  are 
particularly  characteristic  of  pernicious  anaemia.    Under 


BLOOD  8i 

similar  conditions  polychromatophilia  and  basophile 
granulation  are  also  likely  to  occur.  Nucleated  red 
cells  are  usually  an  indication  of  an  attempt  at 
regeneration  of  the  blood.  If  they  are  of  large  size 
(megaloblasts),  the  case  is  probably  one  of  pernicious 
anaemia. 

Normally  the  white  cells  number  from  8,000  to  10,000 
per  cubic  millimetre.  When  this  quantity  is  materially 
increased,  the  condition  is  termed  leucocytosis.  Should 
the  polymorphonuclear  cells  constitute  the  chief  element 
in  the  increased  count,  which  is  the  most  common  type 
of  leucocytosis,  we  may  suspect  acute  inflammations, 
such  as  abscesses,  etc.  Acute  infectious  diseases,  as 
erysipelas,  pneumonia,  diphtheria,  scarlatina,  and  occa- 
sionally debilitating  diseases,  such  as  cancer,  may  show 
a  similar  leucocytosis.  Also,  a  temporary  leucocytosis, 
lasting  several  days,  follows  copious  haemorrhage.  It  is 
important  to  remember  that  this  form  of  leucocytosis 
rarely  occurs  in  tuberculosis,  typhoid  fever,  or  influenza, 
unless  complications  arise. 

An  increased  number  of  white  cells,  of  which  the 
majority  are  lymphocytes,  is  termed  lymphocytosis,  and 
is  best  seen  in  lymphatic  leukaemia.  A  relative  increase 
of  lymphocytes,  the  total  number  of  white  ceUs  re- 
maining about  normal,  is  often  found  in  anaemias  and 
in  enlargement  of  the  lymphatic  glands  from  various 
causes.  It  is  also  a  feature  of  typhoid  fever,  smallpox, 
and  pernicious  anaemia. 

Increase  in  the  percentage  of  eosinophile  leuco- 
cytes (eosinophilia)  occurs  in  many  diseases  of  the 
skin,  nervous  system,  bones,  and  from  intestinal  para- 
sites. 

The  presence  of  myelocytes  in  large  numbers  in  the 
blood  is  an  indication  of  spleno-meduUary  leukaemia. 

6 


82  SYSTEMATIC  CASE-TAKING 

In  small  numbers  they  occur  in  other  forms  of  anaemia 
and  in  diphtheria. 

4.  Widal's  Reaction  is  almost  exclusively  used  as  a 
test  for  typhoid  fever,  though  it  may  be  employed  in 
the  investigation  of  cholera,  Malta  fever,  and  other 
microbic  diseases  (see  Appendix  III.). 

5.  Wassermann's  Reaction  is  practically  never  found 
in  health,  and  in  very  few  diseases  except  syphilis  (see 
Appendix  IV.). 

A  further  examination  of  the  blood  must  in  some 
cases  be  made,  with  the  object  of  obtaining  information 
on  the  following  points :  the  opsonic  power ;  the  saline 
concentration  of  the  serum ;  the  specific  gravity ; 
viscosity  ;  freezing-point ;  alkalinity  ;  coagulability  | 
volume  ;  amount  of  calcium  salts  ;  presence  of  micro- 
organisms ;  presence  of  parasites  [Plasmodium  malarice, 
spirochsete  of  relapsing  fever,  varieties  of  filaria,  the 
trypanosomata).  The  details  of  the  procedures  and 
their  significance  must  be  studied  by  practical  work  in 
the  laboratory,  and  by  reference  to  special  treatises  on 
the  subject.* 

The  Glandular  System. — In  the  neck  enlargement  of 
glands  has  to  be  noted.  That  of  the  cervical  lymphatic 
glands  may  be  the  result  of  inflammations  of  the  mouth 
and  throat  or  tubercular  disease.  Visible  enlargement 
of  the  thyroid  gland  may  be  part  of  the  symptom-com- 
plex known  as  "  exophthalmic  goitre."  A  swelling  just 
below  or  in  front  of  the  ear  on  either  or  both  sides  is 
produced  by  inflammation  of  the  parotid  gland,  and 
usually  indicates  mumps.  Enlargement  of  lymphatic 
glands  in  other  regions  may  be  due  to  tuberculosis  or 
syphilis,  but  if  the  swellings  occur  over  regions  such  as 

*  See  the  article  on  "  Blood  Examination,"  by  Dr.  T.  Houston, 
in  the  author's  "  Dictionary  of  Medical  Diagnosis." 


BLOOD  83 

the  neck,  armpits,  groins,  a  more  widespread  affection 
may  be  suspected,  such  as  Hodgkin's  disease  or  lym- 
phatic leukaemia.  In  the  last-named  affection  the 
blood  examination  gives  the  necessary  clue  to  the  nature 
of  the  case.  Affections  of  other  abdominal  glands  will 
be  referred  to  later. 


CHAPTER  VII 

THE    ABDOMEN 

Topography — Aspect  and  surface  markings — Palpation — Per- 
cussion— Auscultation — The  stomach  and  its  contents — 
Intestines — ^Liver — Spleen — Kidneys — Pelvic  organs. 

Topography. — In  describing  the  condition  of  the  abdo- 
men, the  clinical  clerk  makes  use  of  natural  landmarks 
and  of  imaginary  lines  which  divide  the  abdomen  into 
nine  regions.  The  landmarks  are — the  ensiform  car- 
tilage ;  the  lower  border  of  the  ribs  (the  costal  margin)  ; 
the  crests  and  anterior  superior  spines  of  the  ilia  ;  the 
sjnnphysis  pubis ;  the  umbilicus  ;  the  linea  alba  ;  the 
lineae  semilunares  forming  the  outer  border  of  the  recti 
muscles.  Four  lines  may  be  drawn  on  the  skin — two 
vertical,  through  the  middle  of  Poupart's  ligament ; 
two  horizontal,  one  joining  the  lowest  points  of  the  tenth 
ribs,  the  other  connecting  the  two  anterior  superior 
spines  of  the  ilia.  The  regions  thus  formed  are  the 
hypochondriac,  epigastric,  lumbar,  umbilical,  iliac,  and 
hypogastric  (see  figure.  Chapter  III.). 

Aspect  and  Surface  Markings. — Colour  changes  may 
be  observed  (see  Chapter  II.).  Note  enlarged  veins  due 
to  obstruction  to  venous  return.  If  arranged  somewhat 
radially  from  the  umbilicus  as  a  centre  {caput  medusce), 
the  obstruction  is  in  the  outflow  from  the  portal  circula- 
tion, and  may  be  the  result  of  cirrhosis  of  the  liver  or 

'  84 


THE  ABDOMEN  85 

thrombosis  of  the  portal  vein.  If  the  enlarged  veins  are 
chiefly  at  the  sides  of  the  abdomen,  the  cause  is  more 
likely  to  be  obstruction  of  the  inferior  vena  cava.  The 
umbilicus  is  flattened  and  stretched  in  ascites,  projecting 
in  hernia  and  pregnancy,  depressed  in  fatty  abdominal 
walls  and  oedema.  Linece  alhicantes,  whitish  streaks 
(reddish  when  recent),  indicate  considerable  and  pro- 
longed stretching  of  skin  (pregnancy,  tumours,  ascites, 
fat).  Eruptions  (Chapter  11. ),  with  the  exception  of 
that  of  typhoid  fever,  are  not  specially  liable  to  appear 
on  the  abdomen. 

Palpation. — ^The  patient  lies  on  his  back  in  an  uncon- 
strained position,  so  that  the  abdominal  muscles  may 
be  as  much  relaxed  as  possible.  The  whole  hand  should 
be  employed,  not  the  tips  of  the  fingers  alone,  steady 
but  carefully  regulated  pressure  being  maintained.  Any 
abnormal  mass  is  thus  explored,  and  tender  regions 
investigated.  Pain  thus  elicited  is  characteristic  of 
various  inflammatory  affections,  while  that  due  to 
spasmodic  contractions  of  the  bowel  or  other  hollow 
vise  us  is  usually  relieved  by  pressure.  Should  there  be 
free  fluid  in  the  abdominal  cavity  [ascites),  sudden 
pressure  of  the  abdominal  walls  with  the  tips  of  the 
fingers  may  reveal  a  solid  mass  floating  in  the  fluid. 
Inflammatory  affections  of  the  abdomen  are  sometimes 
to  be  recognized  by  rigidity,  which  is  an  involuntary 
defensive  procedure  of  the  abdominal  muscles.  While 
palpating  the  flanks,  it  is  usually  of  service  to  place  one 
hand  behind  the  patient  and  the  other  hand  in  front. 
By  this  means  structures  in  the  hypochondria  (spleen, 
kidneys,  liver)  can  be  readily  examined.  In  some  cases 
it  is  advisable  to  change  the  posture  of  the  patient  and 
examine  him  in  a  sitting  position,  or  lying  on  one  side 
or  on  the  face. 


86  SYSTEMATIC  CASE-TAKING 

Shape  of  the  A  bdomen. — Retraction  of  the  median  line 
(scaphoid  or  boat-shaped  abdomen)  occurs  in  meningitis, 
cerebral  tumour,  colic.  A  flattening  of  the  abdomen, 
with  the  flanks  somewhat  bulging,  is  found  in  cases  of 
moderate  ascites.  A  larger  collection  of  the  fluid  causes 
the  abdomen  to  be  generally  rounded  and  swollen. 

The  size  of  the  abdomen  is  diminished  in  wasting  from 
any  cause  (starvation,  disease  of  the  digestive  organs, 
cancer).  Enlargement  of  the  abdomen  may  result  from 
gaseous  distension  of  the  bowels  and  stomach.  When 
extreme  it  is  termed  meteorism,  as  seen  in  peritonitis 
or  obstruction  of  the  bowels.  Free  gas  in  the  peritoneal 
cavity  occurs  as  the  result  of  rupture  of  one  of  the  gas- 
containing  viscera.  It  is  to  be  recognized  by  a  con- 
sideration of  the  history  of  the  case — the  sudden  onset 
of  distension,  pain,  probably  dyspnoea,  and  collapse. 
The  absence  of  liver  dulness  on  percussion,  with  dulness 
in  the  flanks,  indicating  fluid  in  the  peritoneal  cavity, 
strongly  supports  this  diagnosis. 

Certain  abnormalities  in  the  movements  of  the  abdom- 
inal wall  may  be  seen  : 

Movements  of  Respiration. — Excessive  abdominal  res- 
piration occurs  when  thoracic  respiration  is  impeded — 
e.g.,  fractured  ribs,  pleurisy,  pericarditis  ;  in  weakness 
of  the  chest  muscles  (rare  nervous  lesions  affecting 
the  thoracic  muscles)  ;  in  pleural  effusion  or  pneumo- 
thorax. Dyspnoea  from  any  cause  exaggerates  both 
abdominal  and  thoracic  respiratory  movements. 
Diminished  abdominal  breathing  is  seen  when  the 
diaphragmatic  movements  are  interfered  with  from  any 
cause — e.g.,  peritonitis,  diaphragmatic  pleurisy,  copious 
pericardial  effusion,  weakness  of  the  diaphragm  (phrenic- 
nerve  paralysis),  abdominal  distension  from  any  of  the 
causes  named  above. 


THE  ABDOMEN  87 

Pulsating  Movements  in  the  abdomen  are  chiefly  those 
of  the  epigastrium,  already  referred  to  in  Chapter  V. 
The  liver  may  at  times  be  found  to  pulsate  ;  this  can 
usually  be  demonstrated  by  bimanual  palpation,  or, 
if  the  abdominal  walls  are  lax,  by  insinuating  the 
fingers  below  the  anterior  edge  of  the  liver.  A  pul- 
sating liver  is  an  evidence  of  serious  valvular  heart 
disease. 

Muscular  Contractions  of  the  viscera  may  be  visible 
or  palpable.  A  peristaltic  movement  of  the  stomach 
may  be  seen  to  traverse  the  upper  part  of  the  abdomen 
with  a  wavelike  movement,  passing  from  left  to  right. 
These  movements  are  only  perceptible  when  the  abdom- 
inal wall  is  thin  and  the  visceral  movements  unusually 
active.  They  almost  always  indicate  obstruction  of 
the  pylorus  (cicatricial  contraction  following  ulceration 
or  cancer).  Vigorous  intestinal  movements  also  give 
reason  to  suspect  obstruction  in  the  gut,  but  the  healthy 
intestinal  wall  may  at  times  be  seen  to  contract  if  the 
abdominal  walls  are  thin. 

Mobility  of  a  tumour,  on  causing  the  patient  to  change 
his  position  or  to  draw  a  deep  breath,  gives  useful 
information  as  to  its  relations.  Enlarged  glands,  in- 
flammatory exudation  or  abscess,  tumour  of  the  pan- 
creas, aneurism  of  the  abdominal  aorta,  are  fixed. 

Movements  caused  by  the  Presence  of  Fluids. — Large 
collections  of  fluid  (ascites,  ovarian  cysts,  hydro- 
nephrosis) give  rise  to  a  definite  fluctuating  wave.  One 
hand  being  placed  flat  over  the  swelling  at  one  side  of 
the  abdomen,  a  sharp  tap  or  fillip  is  given  at  the  opposite 
side,  when  a  wave  is  felt  to  strike  the  palm  of  the  hand 
placed  upon  the  abdomen. 

Movements  produced  by  the  foetus  in  a  pregnant 
uterus  may  be  felt,  and  are  easily  recognized. 


88  SYSTEMATIC  CASE-TAKING 

Percussion. — ^The  note  elicited  by  percussing  the 
abdomen  varies  in  resonance  and  pitch.  Over  the 
stomach  and  large  intestine  the  note  is  more  drumlike 
and  deeper  in  pitch  than  over  the  small  intestine.  The 
whole  surface  of  the  abdomen  is  normally  resonant, 
with  the  exception  of  the  regions  covering  the  liver  and 
spleen.  Hyper-resonance  occurs  in  meteorism,  where 
the  gaseous  distension  of  the  viscera  may  be  sufficient 
to  displace  upwards  the  liver,  spleen,  and  heart,  and, 
indeed,  may  cause  diminution,  or  even  disappearance, 
of  the  liver  dulness.  A  higher  degree  of  resonance  is 
due  to  escape  of  gas  into  the  peritoneal  cavity,  as  a 
result  of  perforation  of  one  of  the  air-containing  viscera. 
The  anterior  area  of  liver  dulness  may  then  be  replaced 
by  a  clear  resonance. 

Diminished  Resonance  indicates  a  diminished  quantity 
of  gases  in  the  abdominal  organs.  Dulness  in  the  flanks 
or  iliac  fossae,  with  clear  resonance  in  the  higher  regions, 
suggests  free  fluid  in  the  abdomen  [ascites) ;  change  of 
posture  of  the  patient,  as  by  turning  him  on  his  side 
or  raising  him  in  bed,  alters  the  relative  position  of  the 
clear  and  dull  areas  of  the  abdomen.  In  cases  of  cyst, 
abscesses,  or  collections  of  ascitic  fluid  restrained  by 
peritoneal  adhesions,  the  change  of  posture  does  not 
effect  to  any  extent  a  change  in  the  situation  of  the  dull 
area.  Ovarian  cysts,  enlarged  spleen,  hydronephrosis, 
or  other  enlargement  of  the  kidney,  cause  a  dull  area 
to  appear  in  the  situation  of  the  swelling,  which,  by 
pressing  aside  the  bowel,  removes  the  resonant  area  to 
one  side  or  to  the  flanks. 

A  dull  note  immediately  above  the  symphysis  pubis 
is  caused  by  the  urinary  bladder  if  it  contain  lo  to 
15  ounces  in  the  case  of  men,  or  15  to  20  ounces  in 
women.     Other  non-resonant  objects  in  the  abdomen 


THE  ABDOMEN  89 

are  enlargements  of  solid  organs,  new  growths,  inflam- 
matory exudation,  abscess. 

Auscultation. — ^The  stethoscope  is  of  but  small  assist- 
ance in  examining  the  abdomen.  In  peritonitis  friction 
sounds  may  occasionally  be  heard.  A  systolic  murmur 
is  to  be  sought  where  aneurism  of  the  abdomen  is  sus- 
pected. The  foetal  heart  may  be  heard  beating  in  preg- 
nancy. One  may  also  hear  the  entrance  of  fluid  into 
the  stomach  from  the  oesophagus  and  of  faeces  into  the 
caecum  (see  below). 

The  Stomach. — ^The  movements  and  shape  of  the 
stomach  may  at  times  be  recognized  by  examination, 
to  facilitate  which  it  is  usually  desirable  to  inflate  the 
stomach.  A  simple  method  is  to  administer  separately 
draughts  of  sodium  bicarbonate  and  tartaric  acid  in 
solution.  The  stomach,  distended  by  the  gas  thus 
generated,  forms  a  rounded  swelling  in  the  epigastrium, 
the  lower  border  of  which  (the  greater  curvature) 
extends  downwards  to  within  an  inch  of  the  umbilicus. 
The  lesser  curvature  lies  under  the  liver,  and  close  up  to 
the  ensiform  cartilage.  When  the  greater  curvature  lies 
below  the  level  of  the  umbilicus,  the  lesser  curvature 
remaining  in  its  normal  position,  the  stomach  is  dilated. 

The  stomach  may  be  in  a  lower  position  than  normal 
without  being  dilated  [gastroptosis).  This  is  best 
observed  with  the  patient  in  the  erect  posture,  as  a 
projection  in  the  umbilical  and  hypogastric  regions  and 
a  recession  in  the  epigastric  region.  A  pyloric  tumour 
may  easily  be  mistaken  for  a  gall-bladder.  The  latter 
is,  however,  more  movable  with  respiration,  while  the 
pyloric  tumour  readily  moves  on  handling.  Should  a 
tumour  be  situated  at  the  cardiac  end  of  the  stomach, 
it  is  recognized  with  difliculty.  Splashing  sounds  can 
be  produced  by  pressing  or  striking  sharply  over  the 


go  SYSTEMATIC  CASE-TAKING 

stomach.  Should  they  be  heard  at  a  time  when  digestion 
ought  to  be  complete — that  is,  six  hours  after  the  last 
meal — it  is  an  evidence  of  dilatation  of  the  stomach. 

Percussion. — ^The  stomach  note  of  percussion  is  some- 
times definite  enough  to  enable  one  to  recognize  the 
dimensions  of  the  organ,  especially  when  it  has  been 
inflated.  After  a  considerable  quantity  of  fluid  has  been 
drunk,  a  crescent-shaped  dull  area,  corresponding  to 
the  greater  curvature  of  the  stomach,  may  be  observed 
on  percussion,  the  patient  being  in  the  upright  posture. 
•  A  combination  of  auscultation  with  percussion  [auscul- 
tatory percussion)  is  at  times  of  service,  and  particularly 
in  the  examination  of  the  stomach.  Whilst  listening 
with  the  stethoscope  placed  over  the  organ,  the  surface 
of  the  abdomen  is  tapped  or  rubbed.  As  soon  as  a  spot 
which  lies  over  the  organ  under  examination  is  struck, 
the  sound  suddenly  becomes  intensified.  It  is  thus 
possible  in  many  cases  to  delineate  the  outline  of  the 
stomach  or  other  organ. 

Auscultation  of  the  stomach  is  only  of  use  in  cases 
where  the  cardiac  orifice  is  obstructed.  The  stethoscope 
is  placed  over  the  stomach,  or  an  inch  to  the  left  of  the 
spine  at  the  level  of  the  eighth  dorsal  vertebra.  The 
patient  is  directed  to  swallow  fluid,  and  in  normal  cases 
a  gurgling  sound  is  heard  six  or  seven  seconds  later. 
When  obstruction  exists,  the  sound  is  either  lost  or 
delayed.  Direct  inspection  of  the  interior  of  the 
stomach  (gastroscopy)  is  rarely  necessary.  The  same 
may  be  said  for  gastrodiaphany,  which  involves  the  intro- 
duction into  the  stomach  of  a  small  electric  lamp. 

Radiography  has  already  proved  of  decided  service  in 
examining  the  condition  of  the  stomach. 

Vomiting. — ^Two  classes  of  vomiting  may  be  dis- 
tinguished— (i)  central  vomiting,  the  result  of  direct 


THE  ABDOMEN  91 

stimulation  of  the  vomiting  centre  in  the  medulla — e.g., 
intracranial  lesions,  emotions,  uraemia,  and  other  toxic 
states  of  the  blood  ;  (2)  reflex  vomiting,  due  to  nervous 
impulses  reaching  the  vomiting  centre  from  the  peri- 
phery— e.g.,  from  the  fauces,  stomach,  kidneys,  testicles, 
ovaries,  ears,  etc. 

The  following  points  concerning  vomiting  have  to  be 
considered  : 

1.  Vomiting  readily  occurs  in  infants  and  young 
children.  It  is  frequently  an  early  sign  of  acute  diseases 
— e.g.,  the  exanthemata. 

2.  The  Relation  of  Vomiting  to  Meals. — A  stricture  at 
the  lower  end  of  the  oesophagus  does  not  permit  the 
food  to  rest  in  the  dilated  gullet  for  any  length  of  time 
before  being  regurgitated.  True  vomiting  may  occur 
immediately  after  eating,  when  the  stomach  is  in  a  state 
of  irritability,  as  in  some  cases  of  acute  gastritis,  gastric 
ulcer,  and  gastric  cancer.  In  chronic  gastritis  the 
interval  between  eating  and  vomiting  is  usually  con- 
siderable (one  or  two  hours),  and  here  the  vomited  food 
is  found  in  a  still  undigested  condition.  In  all  cases  of 
central  or  reflex  vomiting,  except  those  arising  from  the 
stomach,  vomiting  occurs  without  relation  to  meals. 

3.  The  Time  at  which  Vomiting  Occurs. — Morning 
vomiting  occurs  during  pregnancy  ;  change  of  posture 
sets  up  nervous  impulses  from  the  uterus  to  the  vomiting 
centre.  In  chronic  alcoholism  morning  retching  and 
vomiting  occur,  owing  to  the  presence  of  catarrhal 
secretion  in  the  stomach,  which  has  accumulated  during 
the  night.  In  dilatation  of  the  stomach,  especially 
when  due  to  pyloric  contraction,  and  also  in  atonic 
dyspepsia,  vomiting  may  only  appear  at  longer  intervals 
— perhaps  every  two  or  three  days — and  then  copiously. 

4.  The  Relation  of  Pain  to   Vomiting. — ^The  pain  of 


92  SYSTEMATIC  CASE-TAKING 

gastric  cancer,  chronic  gastritis,  acute  dyspepsia,  and 
gastric  ulcer,  is  usually  relieved  by  vomiting.  It  does 
not  relieve  the  pain  from  the  passage  of  gall-stones  and 
kidney-stones,  from  peritonitis  and  from  appendicitis. 

5.  The  Relation  of  Nausea  to  Vomiting. — In  almost  all 
cases  vomiting  is  accompanied  or  preceded  by  nausea. 
Its  absence  is  important,  as  this  often  indicates  a  lesion 
in  the  cranial  cavity. 

6.  Projectile  Vomiting  is  the  sudden  expulsion  of  the 
stomach  contents  without  preliminary  retching,  often 
observed  in  intracranial  lesions. 

Examination  of  the  Stomach  Contents. — ^As  a  rule,  the 
contents  of  the  stomach  must  be  withdrawn  for  ex- 
amination by  means  of  the  stomach-tube.  This  pro- 
cedure is  contra-indicated  in  the  following  conditions: 
In  extreme  weakness,  fevers,  defective  compensation  of 
heart  disease,  arterio-sclerosis,  aneurism  of  the  aorta, 
pregnancy,  and  haemorrhage  from  the  stomach  or  lungs. 

In  order  that  the  contents  of  the  stomach  may  be 
known  before  their  examination,  it  is  usual  to  give  a  light 
meal  after  a  fast  [test  breakfast).  A  couple  of  slices  of 
bread,  with  one  or  two  cupfuls  of  tea  (Ewald's  test  meal), 
is  suitable  ;  but  occasionally  the  examination  is  made 
after  an  ordinary  mixed  meal.  The  following  points  are 
to  be  investigated  in  examining  the  stomach  contents  : 

I.  The  motility  of  the  stomach.  If  an  ordinary  mixed 
meal,  containing  a  fair  proportion  of  proteids,  has  been 
selected  as  a  test  meal,  there  will  be  little  or  no  solid 
matter  found  on  washing  out  the  normal  stomach  after 
seven  hours.  Should  the  movements  be  defective  (atony 
or  dilatation),  solid  masses  may  be  found  remaining  from 
meals  swallowed  many  hours  before.  Ewald's  test  meal 
should  have  left  the  stomach  in  two  hours  if  the  motility 
is  normal. 


THE  ABDOMEN  93 

2.  The  quantity  and  quality  of  the  gastric  juice  may 
be  estimated  by  determining  the  presence  and  the 
quantity  of  free  hydrochloric  acid  in  the  fluid  obtained 
by  filtering  the  stomach  contents.  Place  a  few  drops 
of  GUnzburg's  reagent  (phloroglucin  2,  vanillin  i,  absolute 
alcohol  30)  with  the  same  quantity  of  filtered  gastric 
contents  in  a  white  porcelain  capsule,  and  evaporate  to 
dryness  with  gentle  heat.  A  rose-red  colour  indicates 
free  hydrochloric  acid.  The  total  acidity  of  the  stomach 
contents  and  the  quantity  of  free  hydrochloric  acid 
present  have  at  times  to  be  determined.  For  details,  see 
Appendices  V.  and  VI. 

Free  hydrochloric  acid  may  be  absent  or  diminished 
{hypochlorhydria)  in  cancer  of  the  stomach,  atonic  or 
catarrhal  dilatation  of  the  stomach,  and  severe  anaemia. 
Excess  of  free  hydrochloric  acid  {hyperchlorhydria)  is 
found  in  gastric  ulcer,  in  acute  and  chronic  gastritis, 
and  sometimes  in  nervous  dyspepsia.  In  the  latter 
affection,  however,  the  opposite  condition  of  diminished 
acid  may  occur.  An  excessive  quantity  of  the  gastric 
fluids  generally  (super secretion)  is  the  rule  in  gastric 
neuroses,  gastric  catarrh,  in  the  gastric  crises  of  loco- 
motor ataxia,  and  sometimes  in  gastric  ulcer. 

3.  Abnormal  constituents  may  be  found  in  the  stomach 
— e.g.,  organic  acids,  bile,  faecal  matter,  or  blood. 

Organic  acids  may  be  demonstrated  by  Uffelmann's 
t  est :  To  a  test-tubeful  of  a  i  per  cent,  solution  of  carbolic 
acid  add  i  drop  of  liquor  ferri  perchloridi.  Dilute  till 
the  solution  becomes  an  amethyst-blue  colour.  The 
addition  of  organic  acids  changes  the  blue  colour  to 
yellow.  Free  lactic  acid  is  often  found  in  cases  of 
cancer  of  the  stomach.  It  is  present  (often  in  company 
with  acetic  or  butyric  acid)  when  fermentative  changes 
are  proceeding  in  the  stomach. 


94  SYSTEMATIC  CASE-TAKING 

Bile  is  regurgitated  from  the  duodenum  into  the 
stomach  in  persistent  vomiting  from  any  cause.  It 
occurs  in  acute  and  chronic  gastric  catarrh,  in  vomiting 
from  other  reflex  origins  besides  the  stomach,  and  par- 
ticularly in  intestinal  affections.  In  obstruction  of  the 
bowels,  acute  and  chronic,  and  in  peritonitis,  bilious 
vomiting  is  constantly  observed. 

Fcecal  vomiting  is  a  further  stage  of  the  reverse 
peristalsis  which  causes  bilious  vomiting.  It  occurs  in 
obstruction  of  the  bowels  and  in  peritonitis,  and  is  said 
to  have  been  seen  in  hysteria. 

Blood  may  be  vomited  (hcBmatemesis),  It  may  be  shed 
in  the  stomach  or  duodenum,  or  may  come  from  the 
respiratory  passages  or  oesophagus,  to  be  afterwards 
ejected  from  the  stomach.  The  following  causes  may 
be  mentioned :  (i)  Ulcer  of  the  stomach  or  duodenum. 
Here  the  blood  is  usually  vomited  at  considerable 
intervals,  and  may  be  copious.  (2)  Cancer  of  the 
stomach.  The  blood  is  usually  less  copious,  and  only 
occurs  at  a  late  stage  of  the  disease.  (3)  Gastric  catarrh 
may  infrequently  cause  haematemesis,  but  streaks  of 
blood  may  be  found  after  any  prolonged  attack  of 
vomiting.  (4)  Congestion  and  varicosities  of  the 
capillaries  and  venules  in  the  portal  circuit  often  give 
rise  to  fairly  free  haemorrhage  into  the  stomach,  causing 
haematemesis.  This  may  occur  in  cirrhosis  of  the  liver, 
the  "  nutmeg  liver  "  (cardiac),  and  cancer  of  the  liver. 
(5)  Diseases  of  the  spleen.  (6)  Corrosive  poisons  and 
other  injuries  to  the  stomach  or  oesophagus .  (7)  Aneurism 
of  the  aorta  opening  into  these  organs.  (8)  Blood  states 
giving  rise  to  haemorrhages — e.g.,  purpura,  scurvy,  septic 
inflammations.  As  a  rule,  there  is  no  difficulty  in 
detecting  blood  when  present  in  the  stomach  contents. 
It  may,  however,  be  simulated  by  drugs,  chiefly  bismuth 


THE  ABDOMEN  95 

or  iron.     It  is  best  recognized  by  means  of  the  haemin 
test,  described  in  Chapter  VIII. 

Food,  mucus,  and  saliva,  are  found  in  all  conditions 
causing  vomiting,  and  are  of  no  diagnostic  value  except 
as  to  the  motility  of  the  stomach,  as  mentioned 
above. 

The  Intestines.  —  Normally  the  bowel  cannot  be 
readily  palpated,  but  masses  of  scybala  or  tumours  of 
the  gut  may  be  felt  as  movable  and  often  painless 
sweUings.  Inflammatory  exudations  in  connection  with 
the  bowel  are  painful,  fixed,  and  often  dull  on  per- 
cussion ;  but  if  covered  by  air-containing  bowel,  the 
percussion  note  may  be  resonant.  Auscultation  of  the 
bowel  is  rarely  of  practical  value,  but  the  time  of  the 
arrival  of  food  at  the  ileo-csecal  valve  may  often  be 
determined  by  means  of  the  stethoscope.  In  health  a 
period  of  from  four  to  five  hours  elapses  from  the  meal- 
time (naturally,  breakfast  is  the  only  suitable  meal)  till 
the  first  arrival  of  the  stomach  contents  at  the  caecal 
orifice,  and  in  many  cases  the  fluid  faeces  can  be  heard 
entering  the  large  intestine  as  a  series  of  squirting  noises 
when  the  stethoscope  is  placed  over  the  ileo-caecal  valve 
(Hertz).  Delay  in  this  period  of  the  passage  of  the 
intestinal  contents  is  much  less  common  than  in  the 
large  bowel. 

An  examination  of  the  rectum  has  in  many  cases  to 
be  undertaken.  In  all  cases  of  abnormal  intestinal  dis- 
charge— e.g.,  blood,  pus — and  in  many  cases  of  chronic 
constipation,  digital  examination  of  the  rectum  should 
be  made.  By  this  procedure  not  only  can  the  condition 
of  the  rectal  contents,  if  any,  be  noted,  but  the  adjoin- 
ing structures  can  be  investigated — e.g.,  any  tumour  in 
the  lower  abdomen,  the  uterus  and  ovaries  in  females, 
and  the  prostate  in  males. 


96  SYSTEMATIC  CASE-TAKING 

Inquiry  as  to  the  condition  of  the  faeces  has  to  be 
made,  and,  if  necessary,  they  should  be  examined.  By 
inspection  of  the  evacuation  one  may  observe  the  shape ^ 
colour,  consistency,  odour,  and  the  presence  of  gross 
changes  in  the  constituents  of  the  motion.  It  may, 
however,  be  necessary  to  search  carefully  for  abnormal 
substances — e.g.,  worms,  gall-stones — in  which  case  the 
solid  contents  of  the  stool  must  be  washed  thoroughly 
through  a  sieve.  Under  exceptional  circumstances  it 
is  desirable  to  examine  portions  of  the  stool  under  the 
microscope.  A  minute  quantity  is  placed  on  a  slide. 
If  solid,  it  is  softened  with  a  drop  or  two  of  normal 
saline  solution  (o-6  per  cent,  solution  of  common  salt), 
and  a  cover-glass  applied.  The  film  is  then  examined 
with  a  low  and  medium  power  lens. 

Liver. — Normally  the  lower  edge,  of  the  liver  can  just 
be  felt  in  the  right  nipple  line  during  inspiration,  as  it 
is  depressed  just  below  the  costal  margin.  A  line  drawn 
from  this  point  upwards  and  to  the  left  to  a  point  a  little 
below  the  apex-beat  corresponds  to  the  lower  border  of 
the  organ.  Above,  a  horizontal  line  about  the  level  of 
the  sixth  rib  in  the  right  nipple  line,  the  eighth  rib  in 
the  right  mid-axillary  line,  and  the  tenth  rib  in  the 
right  scapular  line,  marks  the  level  of  absolute  liver 
dulness,  due  to  the  contact  of  that  organ  with  the 
thoracic  wall.  An  area  of  relative  dulness  can  be  traced 
about  an  inch  above  this  level. 

Enlargements  of  the  liver  are  usually  observed  in  the 
direction  of  least  resistance— that  is,  downwards.  The 
enlarged  liver  is  sometimes  visible,  and  nearly  always 
palpable. 

Percussion  of  an  enlarged  liver  is  not  always  satisfac- 
tory, as  the  presence  of  adjacent  air-containing  organs 
gives  resonance  even  over  the  liver,  unless  great  care  be 


THE  ABDOMEN  97 

taken  to  percuss  gently.  Free  fluid  in  the  abdomen  also 
renders  percussion  of  the  liver  difficult. 

The  shape  and  character  of  the  surface  of  the  liver  are 
to  be  determined  by  palpation.  Note  if  the  surface  and 
edge  of  the  liver  are  smooth,  or,  on  the  contrary,  nodular, 
fissured,  or  irregular. 

Diminution,  or  even  disappearance,  of  the  area  of  liver 
dulness  is  to  be  expected  in  intestinal  distension.  Com- 
plete disappearance  of  the  dulness,  however,  is  charac- 
teristic of  the  escape  into  the  peritoneal  cavity  of  gas 
from  a  ruptured  viscus. 

The  gall-bladder,  if  enlarged,  may  be  felt  as  a  rounded 
or  pear-shaped  tumour,  proceeding  downwards  from  the 
right  costal  margin  between  the  nipple  and  median 
lines. 

Spleen. — The  normal  spleen  remains  covered  by  the 
lower  left  ribs,  even  during  forcible  inspiration.  Its 
area  of  dulness  in  the  left  mid-axillary  line  extends  from 
the  ninth  to  the  eleventh  ribs,  its  long  axis  being  parallel 
with  the  eleventh  rib.  When  enlarged,  the  spleen  may 
be  recognized  by  its  situation,  by  its  mobility  with 
respiration,  and  by  the  fact  that  it  usually  retains  its 
shape  and  the  characteristic  notch  on  its  anterior  border, 
even  v/hen  much  enlarged. 

Kidneys. — ^The  chief  source  of  information  as  to  the 
condition  of  these  organs  is  derived  from  an  examina- 
tion of  the  urine  (see  Chapter  VIII.).  By  abdominal 
examination  the  lower  end  of  the  normal  kidney  can 
often  be  felt  during  deep  inspiration,  especially  on  the 
right  side.  Undue  mobility  of  one  or  both  kidneys  (most 
commonly  the  right)  is  readily  detected  by  palpation. 
In  extreme  enlargements  of  the  organ  (hydronephrosis, 
sarcoma,  cystic  disease,  etc.)  the  tumour  may  be  dull  on 
percussion,  except  for  a  band  of  resonance  where  the 

7 


98  SYSTEMATIC  CASE-TAKING 

colon  comes  in  front  of  the  mass.  In  cases  of  moderate 
enlargement  the  kidney  region  is  usually  quite  resonant, 
owing  to  overlying  bowel. 

Pelvic  Organs. — Enlargement  of  the  pelvic  organs  may 
be  detected  by  abdominal  examination.  The  pregnant 
uterus,  after  the  third  month  of  gestation,  rises  into  the 
abdomen,  by  the  sixth  month  reaching  the  umbilicus. 
Fibroid  or  other  tumours  of  the  uterus,  ovarian  tumours, 
solid  or  cystic,  may  attain  a  large  size  and  become 
abdominal.  The  urinary  bladder,  if  it  contain  over 
10  ounces  of  urine,  gives  rise  to  a  swelling,  dull  on  per- 
cussion, immediately  above  the  pubes. 


CHAPTER  VIII 
EXAMINATION  OF  THE  URINE 

Method  of  examination — Naked-eye  examination  (colour,  trans- 
lucency,  odour,  reaction,  density,  quantity) — Chemical 
examination  (albumin,  sugar,  diacetic  acid,  urea,  bile, 
blood,  uric  acid,  indican,  chlorides) — Microscopical  examina- 
tion (pus,  casts,  epithelium,  urates,  phosphates,  oxalates, 
micro-organisms,  etc.) . 

Method  of  Examination. — It  is  recommended  that  the 
following  procedure  be  adopted  in  examining  a  specimen 
of  urine  : 

The  sample  should,  if  possible,  be  taken  from  the 
accumulated  excretion  of  twenty-four  hours.  Observe 
its  colony,  translucency,  and  odour  ;  test  its  reaction  and 
specific  gravity.  Find  out,  if  possible,  the  quantity  of 
urine  passed  in  twenty-four  hours.  Should  the  urine 
be  turbid,  proceed  as  described  below  under  Trans- 
lucency. Test  for  albumin  and  sugar.  Should  the  latter 
be  present,  a  further  examination  for  acetone  and  diacetic 
acid  (and  possibly  pentose)  is  to  be  made.  The  quantity 
of  urea  present  is  next  to  be  determined.  Bile,  blood, 
uric  acid,  and  indican,  may  be  sought. 

Should  any  abnormality  be  discovered  or  any  deposit 
be  present,  examine  microscopically  for  casts,  blood,  pus, 
epithelial  cells,  crystals,  etc.  In  some  cases  a  bacterio- 
logical examination  is  to  be  made.  In  this  event  care 
must  be  exercised  to  obtain  a  specimen  free  from  acci- 
dental contamination. 

99 


loo  SYSTEMATIC  CASE-TAKING 

In  the  following  pages  details  of  the  examination  on 
the  above  lines  are  furnished.  Those  tests  which  have 
been  found  most  serviceable  for  hospital  work  are  alone 
described. 

I.  Naked-Eye  Examination — Colour. — Urine  of  high 
specific  gravity  is  dark  in  colour,  except  that  of  diabetes 
mellitus.  Smoky  urine  usually  contains  a  small  quantity 
of  blood ;  when  dark,  like  porter,  more  copious  blood. 
Various  shades  of  brown  indicate  blood,  carbolic  acid, 
bile,  or  melanin.  Greenish :  bile,  salol,  carbolic  acid. 
Whitish  or  yellowish  :  phosphates,  pus,  oxalates.  Bright 
yellow  after  the  administration  of  santonin.  Aniline 
dyes  taken  by  the  mouth  give  their  colour  in  many  cases 
to  the  urine. 

Translucency. — Normal  urine  is  clear.  After  standing, 
a  semitransparent  mass  of  mucus  collects  at  the  bottom 
of  the  vessel.  A  brick-red  or  pink  deposit  on  cooling 
indicates  urates.  If  turbid,  use  the  following  tests  : 
Place  about  2  drachms  of  turbid  urine  in  a  test-tube, 
add  about  5  drops  of  dilute  acetic  acid.  If  the  urine 
clears,  phosphates  are  present ;  if  not,  boil.  If  it  clears, 
it  is  urates  ;  if  not,  take  a  fresh  quantity  in  the  test-tube 
and  add  a  few  drops  of  strong  nitric  or  hydrochloric  acid. 
If  it  clears,  it  is  oxalate  of  lime  ;  if  not,  it  is  to  be  ex- 
amined microscopically  (see  below). 

Odour  is  increased  in  urine  containing  a  larger  amount 
of  urea  than  normal  (specific  gravity  high) .  It  becomes 
ammoniacal  when  putrefactive  changes  have  occurred 
in  the  bladder.  It  is  sweet-smelling  in  diabetes.  Garlic, 
copaiba,  sandalwood,  give  their  odour  to  the  urine. 

Reaction. — ^Test  with  litmus-paper.  If  the  same  urine 
turns  blue  paper  red  and  red  blue,  it  is  said  to  be  ampho- 
teric. A  quantitative  estimation  of  acidity  is  rarely 
required  (gout,  diabetes).     See  Appendix  VI. 


EXAMINATION  OF  THE  URINE  loi 

Normal  urine  is  acid,  owing  to  the  presence  of  acid 
phosphates.  It  is  rendered  alkaline  by  prolonged  cold 
baths,  by  dyspepsia,  anaemia,  debility,  and  by  the  ad- 
ministration of  alkaline  drugs. 

In  affections  of  the  lower  urinary  passages,  especially 
those  which  interfere  with  the  complete  evacuation  of 
the  bladder — e.g.,  enlarged  prostate  or  stricture  of  the 
urethra — alkaline  and  ammoniacal  urine  is  common. 
Acidity  of  the  urine  is  increased  by  exercise,  hot  baths, 
fevers,  and  by  all  conditions  in  which  the  concentration 
of  the  urine  is  increased.  Gout,  acute  and  chronic 
rheumatism,  diabetes,  and  fevers,  also  a  diet  chiefly  of 
animal  food,  cause  an  increase  in  acidity. 

Specific  Gravity. — Average  healthy  limits  :  1015  to 
1025.  The  ordinary  urinometer  is  the  best  means  of 
observing  the  density.  Read  off  the  mark  on  the  scale 
opposite  the  lowest  point  of  the  meniscus,  or  curved 
surface  of  the  fluid.  If  the  quantity  of  urine  available 
be  too  scanty  to  float  the  urinometer,  the  urine  may  be 
diluted,  and  the  correct  density  is  easily  calculated.  The 
specific  gravity  varies  with  the  temperature.  In  this 
country  the  urinometer  is  usually  graduated  for  a  tem- 
perature of  60°  F.  If  the  temperature  of  the  urine  be 
much  over  or  under  that  figure,  add  i  to  or  subtract  i 
from  the  reading  for  every  5°  F. 

Alterations  in  the  density  depend  chiefly  on  variations 
in  (i)  the  quantity  of  urea  excreted  by  the  kidneys, 
and  (2)  the  bulk  of  water  which  has  passed  through 
them.  Albumin,  if  present,  has  only  a  shght  effect  in 
raising  the  density.  The  specific  gravity  is  increased 
when  the  urine  is  scanty,  as  in  fevers  and  profuse  sweat- 
ing. In  diabetes  mellitus,  however,  where  the  quantity 
is  invariably  increased,  the  specific  gravity  is  raised  by 
the  sugar  in  solution.     Diminished  density  is  observed 


102  SYSTEMATIC  CASE-TAKING 

in  many  conditions  of  cachexia,  in  neuroses,  in  diabetes 
insipidus,  in  the  small  red  kidney,  in  the  small  white 
kidney,  in  hydronephrosis,  and  in  cystic  disease  of  the 
kidneys. 

'  Quantity. — ^The  normal  adult  passes  about  50  ounces 
daily. 

The  quantity  is  increased  (polyuria)  by  cold  (inhibiting 
perspiration)  ;  recent  copious  draughts  of  any  fluid  ; 
hysteria,  epilepsy,  or  simple  emotional  excitement ; 
diuretic  drugs — e.g.,  digitalis,  broom,  nitrate  of  potash, 
etc.  ;  absorption  of  dropsical  effusions ;  diabetes ; 
granular  or  contracted  kidneys  (the  small  red  and  small 
white  kidney)  ;  the  lardaceous  kidney. 

The  quantity  is  decreased  by  excessive  perspiration  ; 
diminished  absorption  of  fluid  from  the  stomach  ;  ex- 
cessive loss  of  fluids,  as  in  diarrhoea,  severe  haemorrhage, 
vomiting,  cholera  ;  fevers ;  shock ;  active  or  passive 
congestion  of  the  kidneys ;  acute  and  chronic  tubular 
nephritis  ;  advancing  dropsy. 

2.  Chemical  Examination. — Albumin  usually  occurs  in 
the  urine  in  the  form  of  serum-albumin,  which  is  often 
accompanied  by  globulin. 

Tests — Heat. — Filter  the  urine  if  turbid  ;  add  4  or 
5  drops  of  dilute  acetic  acid,  unless  the  reaction  is  dis- 
tinctly acid  (excessive  acidity  interferes  with  the  test)  ; 
boil.     A  white  precipitate  is  serum-albumin  or  globulin. 

Nitric  Acid  {Heller's  Test). — A  drachm  of  strong  nitric 
acid  is  placed  in  a  test-tube  ;  on  its  surface  run  carefully 
by  means  of  a  pipette  about  2  drachms  of  urine.  If 
albumin  be  present,  a  precipitate  will  be  foraied  at  the 
junction  of  the  two  fluids.  The  test-tube  should  be 
allowed  to  stand  for  a  couple  of  minutes  if  no  precipitate 
appears,  as  it  may  be  delayed  in  forming  when  the 
quantity  of  albumin  present  is  very  small. 


EXAMINATION  OF  THE  URINE  103 

Fallacies. — A  haze,  found  chiefly  towards  the  upper 
part  of  the  layer  of  urine,  if  unaffected  by  boiling,  is 
mucin  or  nucleo-alhumin  ;  if  it  dissolves  on  heating,  it  is 
hetero-albumose.  If  the  urine  is  of  high  specific  gravity, 
a  precipitate  of  nitrate  of  urea  is  formed.  Dilute  the 
urine  and  test  again,  and  the  deposit  is  not  formed. 
Balsams — e.g.,  turpentine  or  copaiba — in  the  urine  give 
a  cloud  with  nitric  acid,  dissolving  in  ether  or  alcohol. 

Picric  Acid. — Place  equal  parts  of  urine  and  of  a 
saturated  solution  of  picric  acid  in  a  test-tube.  A 
whitish-yellow  cloud  forms  if  there  be  albumin,  albu- 
moses,  nucleo-albumin,  antipyrine,  or  quinine.  All  these 
precipitates,  except  that  of  albumin,  disappear  on 
heating. 

Other  Tests. — Ferrocyanide  of  Potash  with  acetic  acid  : 
a  turbidity  produced  by  albumin  and  albumoses. 

Salicyl-sulphonic  acid  causes  a  white  precipitate  with 
albumin  and  albumoses. 

Biuret  Test. — Copper  sulphate  and  caustic  soda  give 
rose-pink  colour  with  albumoses,  violet  with  albumin. 

If,  as  rarely  happens,  it  is  considered  necessary  to 
distinguish  the  different  varieties  of  proteids  in  the 
urine,  the  picric  acid  and  biuret  tests  suffice.  Albu- 
mosuria has  been  observed  in  cases  of  myeloid  sarcoma, 
acute  yellow  atrophy  of  the  liver,  phosphorus-poisoning, 
in  abscesses,  in  resolving  pneumonia,  and  in  the  puer- 
peral period. 

Note  the  quantity  of  albumin  passed.  Esbach's  albu- 
minometer  is  a  simple  and  sufficiently  accurate  appara- 
tus. Measured  quantities  of  urine  (which  is  to  be 
filtered  if  turbid)  and  a  solution  of  picric  and  citric  acids 
are  placed  in  a  graduated  tube.  The  precipitate  from 
proteids  is  allowed  to  settle  for  twelve  hours,  and  the 
level  to  which   it  has  reached  read  off.    The  figures 


I04  SYSTEMATIC  CASE-TAKING 

represent  the  number  of  grammes  of  dried  albumin  in 
a  litre  of  urine — i.e.,  i  per  i,ooo,  or  yV  P^^  cent. 

Albuminuria  may  be  renal  or  extrarenal.  The  latter 
group  of  conditions  are  of  surgical  interest,  and  are 
usually  associated  with  the  presence  of  pus  [pyuria)  or 
blood  (hcBmaturia)  in  the  urine.  The  source  of  the 
albuminous  and  cellular  addition  to  the  urine  may  be 
the  pelvis  of  the  kidney,  the  ureters,  bladder,  urethra, 
vagina,  or  prepuce.  When  the  pus,  blood,  and  other 
cells,  have  been  removed  by  filtration,  the  amount  of 
albumin  present  is  found  to  be  small,  except  in  cases 
where  the  kidneys  also  are  affected. 

Renal  albuminuria  is  found  in  three  groups  of  condi- 
tions :  (i)  Functional  or  physiological  ;  (2)  pathological, 
without  definite  kidney  disease  ;  (3)  due  to  disease  of 
the  kidneys. 

(i )  Functional  albuminuria  is  of  a  transitory  character, 
and  it  is  believed  that  in  most  cases  there  is  no  anatomical 
change  in  the  kidneys.  There  is,  however,  a  very  general 
opinion  held  that  even  the  transitory  affections  causing 
albuminuria  leave  the  kidneys  in  some  slight  degree 
damaged,  and  that  such  functional  albuminuria  even- 
tually in  many  cases  develops  into  true  nephritis. 

The  following  varieties  of  functional  albimiinuria  may 
be  enumerated :  Periodic,  intermittent,  cyclical,  or 
paroxysmal.  Here  the  albumin  appears  at  more  or  less 
regular  intervals.  Albuminuria  of  adolescents:  chiefly 
among  boys,  usually  increased  by  exercise.  Postural  or 
orthostatic :  it  is  found  on  assuming  the  erect  posture. 
Dietetic  occurs  during  digestion.  Thermal:  heat  or 
cold  may  cause  it. 

These  conditions  are  distinguished  from  the  albu- 
minuria of  nephritis  by  the  absence  of  casts,  except, 
perhaps,  some  hyaline  forms  ;  by  absence  of  the  cardio- 


EXAMINATION  OF  THE  URINE  105 

vascular  changes  of  nephritis  ;  and  by  the  fact  that  the 
albumin  in  the  urine  is  of  temporary  occurrence. 

(2)  Albuminuria  due  to  Disease  elsewhere  than  in  the 
Kidneys. — Slight  temporary  changes  in  the  kidney  epi- 
thelium may  be  found  in  this  group,  which  includes 
febrile,  toxic  (syphilis,  gout,  lead  and  mercury  poisoning), 
and  nervous  albuminuria  (epilepsy,  tetanus,  brain  in- 
juries). 

(3)  Albuminuria  with  definite  kidney  lesion  is  found 
in  the  following  conditions  :  {a)  Congestion  of  the  kidneys, 
either  active  (early  nephritis,  kidney  irritants — e.g.,  tur- 
pentine, cantharides,  alcohol,  etc.)  or  passive  (heart 
disease,  abdominal  tumours).  (6)  Acute  and  chronic 
nephritis  :  here  the  albumin  may  be  abundant,  and  casts 
are  usually  present  in  the  urine  in  considerable  numbers 
and  variety,  (c)  Granular  or  small  red  kidney  :  the 
albumin  is  scanty  or  may  at  times  be  absent,  casts  are 
few,  and  the  quantity  of  urine  passed  is  large,  [d)  Lar- 
daceous  or  amyloid  kidney  :  albumin  often  abundant, 
and  a  large  quantity  of  urine  is  excreted. 

Sugar.— Glucose  is  the  only  sugar  of  clinical  importance, 
and  is  recognized  by  the  following  tests : 

Fehling's  Test. — ^The  reagent  is  composed  of  two  solu- 
tions :  (i)  Sulphate  of  copper,  34' 64  grammes  to  500  c.c. 
water  ;  and  (2)  Rochelle  salts,  180  grammes  ;  caustic 
soda,  70  grammes ;  water,  500  c.c.  Take  equal  parts — 
say  I  drachm — of  the  solutions  in  a  test-tube  ;  boil.  If 
the  fluid  remains  clear,  add  urine  (free  from  albumin, 
and  filtered  if  turbid)  drop  by  drop  till  not  more  than  a 
quantity  equal  to  that  of  the  reagent  has  been  added. 
If  sugar  be  present,  the  blue  colour  is  discharged  and  a 
yellowish-orange  precipitate  of  cuprous  oxide  forms. 

Fallacies. — A  similar  reduction  of  the  copper  salt  is 
produced  by  uric  acid,  excess  of  urates,  and  glycuronic 


io6  SYSTEMATIC  CASE-TAKING 

acid.  Add  to  the  urine  one-fourth  of  its  bulk  of  a  hot 
10  per  cent,  solution  of  acetate  of  lead,  which  precipi- 
tates these  bodies,  but  not  sugar.  Glycuronic  acid  is 
not  fermented  by  yeast. 

Phenylhydrazine  Test  [von  Jaksch). — ^Add  to  a  couple 
of  drachms  of  urine  in  a  test-tube  as  much  phenylhydra- 
zine hydrochloride  as  will  lie  on  the  point  of  a  penknife 
(7  or  8  grains),  and  twice  as  much  sodium  acetate.  Keep 
in  a  beaker  of  boiling  water  for  half  an  hour.  If  glucose 
be  present,  a  yellowish  precipitate  of  glucosazone  forms 
(sheaves  and  bundles  of  needle-like  microscopical  crystals) . 

Fermentation  Test. — It  is  convenient  to  have  a  specially- 
formed  tube  for  this  test,  and  when  suitably  graduated 
it  forms  a  quantitative  test  also.  An  ordinary  Doremus 
ureometer  tube  does  very  well.  Dissolve  a  piece  of 
fresh  yeast  about  the  size  of  a  pea  in  enough  acidulated 
urine  to  fill  the  Doremus  tube,  and  set  it  aside  in  a 
warm  place  for  twelve  hours.  If  glucose  be  present,  gas 
is  generated  (the  volume  of  gas  produced  is  a  measure 
of  the  quantity  of  sugar  present). 

Fallacies. — Urine  may  contain  fermenting  bacteria  ; 
the  yeast  may  be  inert  or  may  be  contaminated  with 
starch.  Test  the  yeast  for  starch  with  tinct.  iodine 
(turns  starch  blue),  and  perform  control  experiments 
with  cane-sugar  solution  and  yeast,  and  with  urine 
without  yeast. 

Quantitative  Tests  for  Sugar — Fehling's  Solution. — 
0-005  gramme  of  glucose  reduces  all  the  cupric  salt  in 
I  c.c.  of  Fehling's  solution  (combined  Nos.  i  and  2). 
Place  10  c.c.  of  urine  diluted  to  100  c.c.  in  a  burette, 
and  run  in  drop  by  drop  into  a  porcelain  capsule  con- 
taining 10  c.c.  of  Fehling's  solution  diluted,  and  kept 
gently  boiling.  The  moment  the  colour  is  discharged 
and  the  precipitate  begins  to  form,  note  the  quantity  of 


EXAMINATION  OF  THE  URINE  107 

urine  expended.     Suppose  this  is  20  c.c,  the  percentage 
of  glucose  is  calculated  thus  : 

0-05  X  100     5 
—~ =-  =  2*5  per  cent. 

A  modification  of  the  above  method  by  Pavy  is  more 
convenient.  By  the  addition  of  ammonia  the  cuprous 
oxide  is  kept  dissolved,  and  the  reaction  is  the  disap- 
pearance of  the  blue  colour.  This  can  be  more  accur- 
ately determined  than  the  point  at  which  Fehling's 
reaction  takes  place.  Pavy's  solution  is  one-tenth  the 
strength  of  Fehling's. 

Fermentation. — ^A  rough  quantitative  method  is  to 
compare  the  specific  gravity  of  the  urine  before  and 
after  fermentation.  For  each  degree  of  density  lost  by 
the  urine  there  is  i  grain  of  sugar  to  the  ounce  of  fluid. 

Sugar  may  be  found  temporarily  in  the  urine  in  a 
variety  of  affections — viz.,  dyspepsia,  gout,  asthma, 
epilepsy ;  and  certain  drugs  and  poisons — e.g.,  chloro- 
form, ether,  antipyrine,  carbonic  oxide.  Should  the 
glycosuria  persist,  and  be  accompanied  by  thirst,  poly- 
uria, and  wasting,  the  patient  is  suffering  from  diabetes 
mellitus.  The  diagnosis  of  this  disease  is  obvious  as  a 
rule,  but  in  some  cases  there  is  no  loss  of  flesh,  and  it  is 
only  by  examination  of  the  urine  or  by  the  discovery  of 
some  of  the  usual  diabetic  sequelae  (cataract,  carbuncle, 
peripheral  neuritis)  that  the  condition  is  recognized. 

Acetone  {LegaVs  Test). — ^Alkalinize  the  urine  with  liq. 
potassae,  and  add  a  solution  (o'l  gramme  to  15  c.c. 
water)  of  nitroprusside  of  soda.  Acetone  gives  a  ruby- 
red  colour,  becoming  violet  on  acidifying  with  acetic 
acid. 

Aceto-Acetic  Acid  (Diacetic  Acid). — Continue  adding  a 
few  drops  of  dilute  liquor  ferri  perchloridi  till  the  pre- 


io8  SYSTEMATIC  CASE-TAKING 

cipitate  of  ferri  phosphate  ceases.  Filter,  and  add  a 
few  more  drops  of  iron.  Aceto-acetic  acid  gives  a  violet- 
red  colour. 

Fallacies. — If  the  urine  has  been  previously  boiled, 
this  reaction  fails.  The  same  reaction  is  given  by  anti- 
pyrine,  salicylates,  and  carbolic  acid. 

Acetone  and  diacetic  acid  are  derivatives  of  hydroxy- 
butyric  acid,  and  when  present  they  signify  grave 
metabolic  disturbance.  They  occur  in  severe  diabetes, 
and  the  diminished  alkalinity  of  the  blood  found  in  this 
disease  is  due  to  hydroxy  butyric  acid. 

Pentose  reduces  copper  like  glucose,  and  forms  pento- 
sazones  with  phenylhydrazine,  but  does  not  ferment. 

Orcin  Test  [BiaVs). — Reagent  consists  of  hydrochloric 
acid  (30  per  cent.),  500  c.c.  ;  orcin,  i  gramme  ;  solution 
of  ferric  chloride  (10  per  cent.),  25  drops.  Boil  5  c.c. 
of  this,  add  a  few  drops  of  urine  ;  a  green  colour  indi- 
cates pentoses. 

The  occasional  appearance  of  this  form  of  sugar  in 
the  urine  may  give  rise  to  an  erroneous  diagnosis  of 
diabetes.    The  nature  of  its  occurrence  is  uncertain. 

Urea. — ^The  sample  should,  if  possible,  be  taken  from 
a  mixture  of  twenty-four  hours'  urine. 

The  presence  of  urea  is  ascertained  by  evaporating  a 
few  drops  of  urine  with  a  drop  of  nitric  acid  on  a  slide. 
Nitrate  of  urea  is  found  as  hexagonal  or  rhombic 
crystals. 

The  quantity  of  urea  is  to  be  determined  by  setting 
free  and  measuring  its  nitrogen,  of  which  there  are 
372  c.c.  to  each  gramme  of  urea.  This  is  effected  by 
the  action  of  alkaline  sodium  hypobromite  (2  c.c.  of 
bromine  in  23  c.c.  of  a  40  per  cent,  solution  of  caustic 
soda).  The  most  convenient  apparatus  for  the  measure- 
ment of  the  gas  is  Hind's  modification  of  Doremus's 


EXAMINATION  OF  THE   URINE  109 

ureometer.  Larger  and  more  accurate  instruments  are 
Gerrard's  and  Dupre's  ureometers. 

The  average  quantity  of  urea  excreted  in  health  is 
2  per  cent,  of  the  total  urine  passed.  Increase  in  this 
amount  {azoturia)  results  from  excessive  nitrogenous 
diet  or  excessive  destruction  of  nitrogenous  tissues.  A 
diminished  output  of  urea  is  the  result  of  deficiency  of 
nitrogen  in  the  food,  disease  of  the  liver  (cirrhosis, 
cancer,  acute  yellow  atrophy),  and  renal  inefficiency 
(Bright's  disease,  cystic  kidney). 

Bile. — ^The  urine  is  coloured  dark  yellow  to  brown  or 
green,  with  yellow  froth,  and  stains  linen  yellow. 

Gmelin's  Test. — Fuming  nitric  acid  oxidizes  the  bile- 
pigment,  producing  layers  or  rings  of  colours  :  green, 
blue,  violet,  red,  and  yellow.  Pass  the  urine  through 
white  filter-paper  ;  a  drop  of  fuming  nitric  acid  is  placed 
on  the  bile-stained  paper. 

The  presence  of  bile-pigment  in  the  urine  indicates 
in  most  cases  obstruction  to  the  outflow  of  bile. 

Blood,  if  scanty,  imparts  a  smoky  appearance  to  the 
urine  ;  if  copious,  it  is  brownish-black. 

Guaiacum  Test. — Moisten  a  small  piece  of  lint  with 
the  urine,  add  a  drop  of  freshly -prepared  tincture  of 
guaiacum,  and  on  the  same  spot  a  drop  of  ozonic  ether. 
If  blood  is  present,  a  blue  colour  appears.  The  same 
test  may  be  done  by  the  contact  method.  A  drachm 
of  ozonic  ether  with  a  few  drops  of  tincture  of  guaiacum 
are  placed  in  a  test-tube  ;  a  drachm  or  so  of  urine  is 
placed  on  the  surface  of  this  fluid  by  means  of  a 
pipette.  A  blue  layer  forms  at  the  junction  of  the  two 
fluids. 

Fallacies. — Iodides  and  saliva  give  a  similar  reaction. 

Heller's  Test. — Alkalinize  the  urine  strongly  with 
liquor  potassae  ;  boil.     A  brownish-red  deposit  consists 


no  SYSTEMATIC  CASE-TAKING 

of  earthy  phosphates  and  hsematin.    The  supernatant 
fluid  is  greenish-coloured. 

Fallacies. — Rhubarb,  senna,  and  santonin,  give  a 
similar  result.  If  the  urine  was  originally  alkaline,  it 
gives  no  such  reaction  until  a  little  lime-water  has  been 
added. 

Hcemin  Test. — Place  a  little  of  the  urinary  sediment 
on  a  glass  slide,  add  a  minute  crystal  or  two  of  common 
salt,  place  a  cover-glass  on  it,  run  in  a  drop  of  glacial 
acetic  acid,  warm  gently,  allow  it  to  cool,  and  mahogany- 
red  rhombic  crystals  of  hsemin  will  be  found  by  the 
microscope. 

Spectroscope. — A  convenient  pocket  spectroscope  can 
be  obtained  which  will  show  the  absorption  bands  of 
haemoglobin. 

Often  the  blood-corpuscles  can  be  recognized  by  the 
microscope  {hcBmaturia).  They  do  not  lie  in  rouleaux, 
and  may  be  misshapen.  If  the  chemical  tests  show 
blood,  but  the  red  corpuscles  are  not  found  microscopi- 
cally, the  condition  is  termed  hcemogloUnuria. 

Blood  may  come  from  any  portion  of  the  urinary 
tract,  from  the  meatus  to  the  kidney — viz.,  urethral 
ulcers  or  injuries ;  bladder  lesions — e.g.,  prostatitis,  vari- 
cose veins,  villous  growths,  tubercular  or  malignant 
ulceration,  stone  ;  in  the  ureter  and  pelvis  of  the  kidney 
tubercular  disease,  malignant  tumours,  and  renal  cal- 
culus, cause  bleeding  ;  haemorrhage  from  the  kidney 
occurs  especially  in  acute  and  subacute  nephritis,  but 
also  in  chronic  nephritis  and  granular  kidney,  in  haemo- 
philia, with  some  acute  fevers,  and  from  certain  tropical 
parasites. 

Hcemoglohinuna,  the  result  of  destruction  or  haemo- 
lysis of  the  red  corpuscles,  occurs  as  a  result  of  certain 
poisons  in  the  blood — e.g.,  carbolic  acid,  chlorate  of 


EXAMINATION  OF  THE  URINE  iii 

potash  in  large  doses,  carbon  monoxide,  quinine,  toxins 
of  fevers  (scarlet,  yellow,  typhoid).  A  paroxysmal 
haemoglobinuria  sometimes  occurs,  apparently  caused 
by  some  exposure  or  excessive  exercise  in  susceptible 
individuals. 

Uric  Acid. — Normally  uric  acid  is  not  found  free  in 
the  urine,  but  as  urates  of  sodium,  potassium,  and  cal- 
cium. If  an  acid  urine  stands  for  some  time,  a  scanty 
reddish  deposit  of  uric  acid  comes  down.  It  is  com- 
posed of  microscopical  pink  -  coloured  crystals  of  a 
variety  of  forms.  Chemically  it  is  detected  by  the 
murexide  test,  which  also  indicates  urates.  A  little  of 
the  deposit  is  placed  in  a  porcelain  capsule  with  a  few 
drops  of  dilute  nitric  acid,  and  evaporated  to  dryness. 
Add  a  drop  or  two  of  ammonia  to  the  yellowish  residue, 
and  a  violet  colour  appears  ;  add  a  drop  or  two  of  caustic 
potash,  and  the  colour  becomes  more  blue. 

An  excessive  excretion  of  uric  acid  signifies  an  unduly 
active  proteid  metabolism,  as  seen  in  a  variety  of  wasting 
and  acute  diseases. 

Indican,  the  indoxyl-sulphate  of  potash,  is  normally 
present  in  the  urine  in  small  quantity.  It  is  increased 
in  constipation,  intestinal  obstruction,  suppuration, 
and  excessive  proportion  of  animal  food. 

Jaffe's  Test. — ^Take  about  2  drachms  each  of  urine  and 
strong  hydrochloric  acid ;  add  a  few  drops  of  a  5  per  ceat. 
solution  of  calciimi  hypochlorite  till  a  blue  colour 
appears  ;  add  a  little  chloroform,  and  shake  weU.  On 
standing,  the  chloroform  coloured  by  indican  settles  to 
the  bottom  as  a  blue  layer  of  fluid. 

Chlorides  may  at  times  be  estimated.  Normally  they 
exist  (chiefly  in  the  form  of  chloride  of  sodium)  in  the 
urine,  12  to  14  grammes  being  excreted  daily  by  a 
healthy  adult. 


112  SYSTEMATIC  CASE-TAKING    ■ 

Mohr's  Test. — To  lo  c.c.  urine  add  30  to  50  c.c.  dis- 
tilled water  and  2  or  3  drops  of  a  10  per  cent,  solution 
of  potassium  chromate.  From  a  burette  run  in  nitrate 
of  silver  solution  (29-042  grammes  nitrate  of  silver  to 
I  litre  of  water)  until  a  permanent  red  colour  is  obtained, 
and  note  the  quantity  of  silver  solution  expended.  For 
every  cubic  centimetre  of  silver  solution  there  is  present 
Q-oi  gramme  of  sodium  chloride.  The  result  is  a  little 
too  high,  as  other  substances  are  present  which  also 
unite  with  the  silver  solution  ;  deduct,  therefore,  i  c.c. 
from  the  amount  of  silver  solution  used. 

Two  urinary  reactions  having  reference  to  the  diag- 
nosis of  typhoid  fever  may  be  here  referred  to — viz., 
Ehrlich's  diazo  reaction  (see  Appendix  VII.)  and  Russo*s 
methylene-hlue  reaction  (see  Appendix  VIII.). 

3.  Microscopical  Examination. — ^The  deposit  should  be 
centrifugalized. 

Blood. — See  above. 

Pus. — ^The  deposit  resembles  phosphates,  but  if  the 
urine  is,  or  is  rendered,  alkaline,  it  has  a  slimy,  ropy 
consistency.  Microscopically  the  pus  cells  are  seen  to 
be  larger  than  red  blood  cells,  with  a  divided  nucleus. 
Add  acetic  acid  to  the  slide,  and  the  bodies  of  the  cells 
become  transparent,  while  their  nuclei  remain  visible. 

If  from  the  bladder  (tuberculosis,  cystitis,  calculus, 
prostatic  enlargement,  or  stricture),  the  reaction  is 
usually  alkaline  ;  but  if  due  to  Bacillus  coli,  it  is  acid. 
It  is  also  usually  acid  if  the  seat  of  the  disease  is  the 
ureters  or  kidneys. 

After  filtering  pus  cells  from  the  urine,  a  little  albumin 
is  found  in  the  filtrate.  Should,  however,  a  considerable 
quantity  of  albumin  be  present,  it  is  probably  due  to 
renal  albuminuria. 

Tube-casts  are  moulds  of  the  renal  tubules  formed  of 


EXAMINATION  OF  THE   URINE  113 

albuminous  material,  to  which  have  been  added  a 
variety  of  substances  giving  the  respective  characters 
to  the  casts.  The  following  varieties  may  be  enumer- 
ated :  Hyaline  casts :  clear,  semitransparent.  Epi- 
thelial casts  :  more  or  less  completely  composed  of  epi- 
thelial cells.  If  studded  with  granules,  the  detritus  of 
broken-up  cells,  they  are  granular  casts.  These  granules 
may  be  largely  composed  of  fat  droplets,  which,  if  abun- 
dant, give  their  name  io  fatty  casts.  Blood  casts  have  a 
number  of  red  corpuscles  incorporated  in  them.  If  the 
ceUs  are  white  corpuscles,  the  casts  are  termed  leucocytic 
casts.  Waxy  casts  are  probably  epithelial  or  hyaline 
casts  which  have  undergone  degeneration  owing  to  their 
retention  in  the  tubules  for  a  considerable  time.  They 
are  broad,  pale,  often  yellowish,  and  highly  refractive, 
with  sharp  outline. 

Casts  are  almost  invariably  an  indication  of  disease 
of  the  kidneys,  the  chief  exception  being  the  fact  that 
hyaline  and  occasionally  granular  casts  are  sometimes 
found  in  the  urine  of  cases  of  jaundice,  where  the  kidney 
is  not  apparently  affected  ;  also,  hyaline  casts  may  be 
found  in  some  cases  of  functional  albuminuria. 

Any  or  all  of  the  varieties  of  casts  named  may  be 
found  in  cases  of  nephritis,  but  by  observing  which  type 
occurs  most  frequently  in  any  case  some  help  may  be 
gained  in  the  diagnosis.  Thus,  blood  casts  are  common 
in  acute  nephritis,  and  at  times  in  chronic  nephritis. 
Epithelial,  granular,  and  fatty  casts  are  characteristic 
of  tubal  nephritis,  and  are  less  often  seen  in  the  con- 
tracted forms  {small  white  and  small  red  kidney). 
Waxy  casts  are  not  often  found  in  cases  of  amyloid 
kidney,  but  are  an  evidence  of  chronicity.  Hyaline 
casts  are  of  little  or  no  diagnostic  value. 

Epithelial  cells  of  many  forms  may  be  found  in  the 

8 


114  SYSTEMATIC  CASE-TAKING 

urine — viz.,  squamous  cells  from  the  superficial  layers 'of 
bladder  mucous  membrane,  similar  shaped  but  larger 
flattened  cells  from  the  vagina  in  females,  cubical  or 
tailed  cells  from  the  deeper  layers  in  the  bladder,  and 
the  somewhat  smaller  columnar  cells  (or  rounded  with 
large  undivided  nucleus)  from  the  kidney  tubules. 

Urates  form  the  ordinary  brick-red  deposit  in  the 
urine.  The  commonest  are  the  amorphous  urates  of 
sodium,  potassium,  and  ammonium ;  but  crystalline 
forms  may  be  observed — viz.,  urate  of  sodium,  urate  of 
ammonium  (more  or  less  spherical  bodies  with  spines). 

Phosphates  are  precipitated  in  alkaline  urine,  and  are 
commonly  found  as  an  amorphous  deposit  of  calcium, 
or  more  rarely  magnesium  phosphate.  Crystallized 
phosphates  in  smaller  quantity  are  usually  found  with 
the  amorphous.  The  "  triple  phosphate,"  or  ammonio- 
magnesium  phosphate,  is  common,  and  is  seen  in  the 
well-known  "  knife-rest  "  or  '*  coffin-lid  "  and  feathery 
star  crystals.  The  so-called  "  stellar  phosphates  "  are 
often  found  in  acid  urine. 

The  presence  of  phosphates  is  usually  merely  a  result 
of  alkaline  reaction  of  the  fluid,  and  is  common  in  cases 
of  nervous  dyspepsia.  A  definite  increase,  however,  in 
the  quantity  of  phosphates  (phosphaturia)  is  seen  in 
wasting  diseases,  in  rickets,  in  severe  anaemia,  and  in 
some  affections  of  the  nervous  system. 

Oxalate  of  lime  occurs  in  urine  as  octahedral  or  "  en- 
velope," or  more  rarely  as  "  dumb-bell  "  crystals.  It 
may  be  found  after  indiscretions  in  diet.  Certain  vege- 
tables (rhubarb,  tomatoes,  onions),  want  of  exercise, 
emotional  disturbance,  all  tend  to  its  appearance.  It 
may  cause  pain  and  irritation  in  the  urinary  tract,  and, 
in  common  with  uric  acid,  phosphates,  and  other  crystals, 
may  go  to  form  calculi. 


EXAMINATION  OF  THE  URINE  115 

Carbonate  of  lime  rarely  occurs  in  urine,  and  is  usually 
an  amorphous  deposit  dissolving  with  effervescence  on 
the  addition  of  an  acid. 

Cystin,  cholesterin,  xanthin,  leucin,  and  tyrosin,  are 
rare  constituents  of  urine.  The  last  two  occur  in  serious 
disease  of  the  liver,  in  pernicious  anaemia,  and  in  phos- 
phorus-poisoning. Fat  is  found  in  droplets  free  in  the 
urine  in  some  cases  of  fatty  degeneration  of  the  urine. 
Spermatozoa,  "  cylindroids,"  "  prostatic  threads,"  para- 
sites, masses  of  bacteria,  and  foreign  bodies  of  all  descrip- 
tion, may  be  recognized  in  the  urine. 

Micro-organisms. — See  Appendix  II. 


CHAPTER  IX 

NERVOUS  SYSTEM 

Routine  method  of  examination — Defects  of  movement — Loss 
of  power — Increased  muscular  action — Disorderly  move- 
ments— Reflexes — Sensory  disturbances — Psychical  func- 
tions. 

Routine  Method  of  Examination. — The  condition  of  the 
nervous  system  is  to  be  investigated  by  a  methodical 
examination.    The  following  routine  is  recommended  : 

1.  Observe  if  any  defect  of  movement  exists.  Exclude 
by  careful  examination  any  lesion  of  the  joints,  bones, 
or  muscles,  which  might  affect  the  motor  functions  of 
the  part.  In  connection  with  movements,  the  tone  and 
nutrition  of  the  muscles  are  to  be  examined. 

2.  The  condition  of  the  reflexes  is  to  be  observed, 
including  cutaneous,  deep,  vascular,  and  visceral  reflex 
functions. 

3.  Next,  the  sensory  functions  are  to  be  examined, 
including  common  sensation,  muscular  sense,  pain,  heat, 
cold,  abnormal  sensations,  and  the  special  senses. 

.4.  Lastly,  the  higher  or  intellectual  faculties  are  to  be 
studied,  including  consciousness,  the  state  of  the  memory, 
power  of  concentration,  attention  and  understanding, 
the  capabilities  of  speech  and  writing. 

I.  Defects  of  Movement. — In  order  to  inquire  into  the 
state  of  any  muscle  or  group  of  muscles,  the  patient  is 
directed  to  perform  various  acts  which  would  bring  the 

116 


NERVOUS  SYSTEM  117 

muscles  into  play.  He  must,  first,  as  far  as  possible, 
use  the  limbs  as  a  whole  and  the  trunk  muscles.  Thus, 
he  is  directed  to  turn  over  on  either  side  in  bed,  to  sit 
up,  to  draw  up  and  cross  his  legs,  raise  his  arms  in  dif- 
ferent directions.  He  should  stand,  if  possible,  and 
walk.  His  mode  of  walking  and  turning,  rising  and 
sitting,  are  to  be  observed.  The  separate  groups  of 
muscles,  and  even  individual  muscles,  may  be  investi- 
gated by  testing  their  ability  to  execute  the  various 
actions  which  they  should  normally  perform.  During 
this  part  of  the  examination  the  state  of  nutrition  or 
tone  of  the  muscles  is  to  be  observed.  The  firm  con- 
sistency of  normal  muscles,  as  felt  by  the  fingers,  may 
be  lost ;  or,  on  the  other  hand,  even  in  a  paralyzed  limb, 
it  may  be  equal  to  or  greater  than  that  of  healthy 
muscles.  A  further  investigation  of  muscular  nutrition 
by  electrical  stimulation  has  at  times  to  be  carried  out 
(see  Appendix  IX.).  In  this  connection  the  condition  of 
the  reflexes  has  also  to  be  taken  into  consideration  (see 
below).  Efficiency  of  movement  depends  on  the  in- 
tegrity of  the  motor  tract,  which  is  the  pathway  of  nerve 
impulses  proceeding  from  the  motor  area  of  the  cortex 
to  the  efferent  nerve  endings  in  the  muscles.  Clinically 
we  recognize  two  divisions  or  segments  of  the  motor 
tract.  The  upper  segment  [central  neurons)  extends 
from  the  cortex  to  the  lower  motor  centres  or  nuclei 
from  which  the  respective  cranial  and  spinal  efferent 
nerves  arise.  These  nuclei  in  the  case  of  the  cranial 
nerves  lie  in  the  crura,  pons,  and  meduUa,  below  the 
decussation  of  the  fibres  of  the  upper  segment,  and  for 
the  spinal  nerves  the  nuclei  are  situated  in  the  anterior 
horns  of  the  grey  m.atter  of  the  cord.  In  addition  to  the 
function  of  directing  efferent  impulses,  the  nuclei  exer- 
cise a  trophic  influence  on  the  nerves  and  muscles  in 


ii8  SYSTEMATIC  CASE-TAKING 

connection  with  them.  Destruction  of  the  nuclei  or  of 
the  motor  nerves  proceeding  from  them  causes  atrophy 
of  the  muscle  fibres  supplied  by  the  affected  nerves. 
The  portions  of  the  motor  tract  from,  and  including, 
the  ganglion  cells  forming  the  nuclei  to  the  peripheral 
ends  of  the  nerve  fibres  are  known  as  the  peripheral 
neurons,  or  lower  segment  of  the  motor  tract. 

Three  disturbances  of  the  normal  movements  may  be 
observed :  (i)  Weakened  or  abolished  ;  (2)  increased  or 
exaggerated  ;  and  (3)  perverted  or  disorderly  move- 
ments. 

(i)  Weakened  or  Abolished  Movements,  the  result  of 
disease  of  the  central  or  peripheral  nervous  system,  are 
described  as  paralysis  when  the  loss  of  power  in  any 
lesion  is  complete,  and  paresis  when  partial. 

Two  main  groups  of  paralysis  may  be  recognized  : 
(i.)  Spastic  or  tonic  paralysis  ;  and  (ii.)  flaccid  or  atrophic 
paralysis. 

(i.)  Spastic  paralysis  results  from  a  lesion  of  the  central 
or  upper  neurons  ;  ■  there  is,  therefore,  no  interference 
with  the  nutrition  of  the  affected  muscles,  and  their 
tone  is  equal  to  or  greater  than  that  of  normal  muscles. 
On  making  the  patient  perform  some  movement,  his 
affected  limbs  are  noticed  to  be  not  only  feeble,  but  also 
stiff.  The  reflexes  are  exaggerated  in  most  cases.  Any 
lesion  which  interrupts  the  passage  of  nerve  impulses 
from  the  motor  area  of  the  cortex  to  the  nuclei  may 
cause  a  paralysis  of  this  description.  It  is  therefore 
found  in  transverse  interruption  of  the  cord  from  any 
cause  (compression,  myelitis,  haemorrhage  into  the 
cord) ;  sclerotic  changes  in  the  upper  segment  of  the 
motor  tract,  either  in  the  brain  or  spinal  cord  ;  cerebral 
disease  or  injury  involving  the  motor  tract  (see  Appendix 
XI.). 


NERVOUS  SYSTEM  119 

(ii.)  Flaccid  paralysis  is  recognized  by  the  extreme 
wasting  of  the  muscles,  which  are  soft  and  flaccid  when 
handled  ;  the  limb  is  loose  and  flail-like  in  its  move- 
ments. The  lesion  which  produces  flaccid  paralysis  is 
situated  in  the  lower  or  peripheral  neuron,  whereby  not 
only  the  voluntary  power  of  movement  is  lost,  but  the 
nutrition  rapidly  deteriorates,  and  the  reflexes  are 
diminished  or  abolished.  The  disease  may  be  either 
in  the  central  organs  (brain  or  cord)  or  in  the  peripheral 
nerves.  In  the  former  case  the  anterior  horns  of  the 
cord,  or  the  nuclei  of  the  cranial  nerves,  are  injured, 
either  by  inflammatory  or  degenerative  changes  as  a 
rule,  though  traumatism,  tumours,  haemorrhage,  and 
other  causes,  may  occur.  The  peripheral  nerve  lesions 
are  varied  in  their  origin  and  in  their  result  according 
to  the  situation  and  action  of  the  affected  muscles  (see 
Appendix  XL). 

The  Regions  of  the  Body  affected. — The  loss  of  power 
may  be  bilateral.  When,  as  in  the  majority  of  cases,  this 
is  due  to  a  lesion  of  the  cord,  the  condition  is  termed 
paraplegia.  If  the  damage  is  below  the  cervical  region, 
the  legs  alone  are  paralyzed  (paraplegia  cruralis) ;  if  at 
or  above  the  cervical  enlargement  of  the  cord,  all  four 
limbs  are  powerless  (paraplegia  totalis). 

An  injury  or  disease  of  the  brain  which  interrupts 
the  fibres  from  both  sides  of  the  brain  may,  less  fre- 
quently, be  the  cause  of  a  bilateral  paralysis,  which  is 
termed  diplegia  or  cerebral  paraplegia.  In  some  cases 
the  limbs  of  one  side  and  the  facial  or  eye  muscles  of 
the  other  are  paralyzed  (crossed  or  alternate  paralysis)  ; 
here  the  lesion  is  likely  to  have  damaged  the  nucleus  of 
the  sixth  or  seventh  nerve  in  the  pons,  or  the  third  or 
fourth  nerve  in  the  crus,  together  with  the  fibres  to  the 
limb  from  the  other  side  of  the  brain. 


I20  SYSTEMATIC  CASE-TAKING 

A  bilateral  paralysis  may  also  be  caused  by  disease  of 
the  peripheral  nerves.  This  is  most  likely  to  be  the 
result  of  some  blood  poison  (multiple  neuritis) ;  it  is 
found  that,  while  such  poisons  may  injuriously  affect 
any  nerve,  they  have  in  many  cases  a  selective  influence 
which  causes  certain  nerves  to  be  most  vulnerable  to 
the  respective  poisons.  Thus  alcohol  attacks  by  prefer- 
ence the  external  popliteal  nerve,  giving  rise  to  inability 
to  flex  the  foot  dorsally,  to  extend  the  toes  on  the 
dorsum  of  the  foot,  and  to  raise  the  outer  edge  of  the 
foot.  This  paralysis  causes  foot-drop  and  the  so-called 
steppage  gait,  in  which  the  knee  has  to  be  raised  unduly 
high  in  order  that  the  toes  may  clear  the  ground.  The 
same  nerve  is  especially  liable  to  be  affected  by  the 
poison  of  diphtheria,  diabetes,  beri-beri,  etc.  Diphtheria 
has  also  a  preference  for  the  soft  palate  and  for  the 
muscles  of  the  eye,  especially  for  the  ciliary  muscles 
which  control  accommodation.  Lead-poisoning  selects 
mainly  the  extensor  muscles  of  the  forearm  (the  supinator 
longus  escapes),  causing  the  condition  known  as  wrist- 
drop ;  this  is  more  commonly  symmetrical.  A  one-sided 
wrist-drop  often  occurs  as  a  result  of  injury  to  the 
musculo-spiral  nerve  ;  this  may  result  from  pressure  of 
the  arm  over  the  back  of  a  chair  during  sleep  [Saturday 
night  palsy). 

A  paralysis  of  one  side  of  the  body  only  is  not  often  due 
to  spinal  cord  disease,  where  damage  from  disease  or 
injury,  even  if  it  begin  at  one  side  of  the  cord,  is  apt  to 
affect  the  adjoining  nerve  structures  controlling  both 
sides  of  the  body.  It  is  in  the  brain  or  in  the  peripheral 
nerves  that  a  one-sided  paralysis  [hemiplegia)  is  likely 
to  originate. 

The  lesion  of  the  brain  causing  paralysis  is  of  a  de- 
structive character  ;  it  is  commonly  of  vascular  origin — 


NERVOUS  SYSTEM  12 1 

either  haemorrhage  from  a  ruptured  artery,  embolism,  or 
thrombosis.  Tumours,  abscesses,  or  degenerations,  are 
also  possible  causes.  A  consideration  of  the  mode  of 
onset  of  the  paralysis,  the  condition  of  the  bloodvessels, 
heart,  and  kidneys,  the  habits  and  age  of  the  patient, 
render  a  diagnosis  of  the  cause  of  hemiplegia  possible. 

The  seat  of  the  lesion  is  in  many  cases  the  internal 
capsule,  where  the  fibres  of  the  motor  tract  are  brought 
together  in  a  small  space.  If  lower  down  the  motor 
tract,  the  nuclei  of  motor  nerves  are  likely  to  be  damaged, 
causing  the  crossed  paralysis  referred  to  above.  When 
higher  than  the  internal  capsule,  one  limb  only  may 
be  paralyzed  (monoplegia),  or  the  subcortical  or  cortical 
regions  may  be  involved,  giving  rise  to  twitchings  or 
convulsions. 

A  not  uncommon  cause  of  one-sided  paralysis  is 
infantile  paralysis  ;  here  the  lesion  is  an  acute  inflamma- 
tion involving  the  anterior  cornua  of  the  cord,  and  in 
many  instances  only  a  limited  portion  of  the  cord  is 
affected,  though  it  is  also  common  for  regions  on  both 
sides  of  the  body  to  be  affected.  A  chronic  inflammation 
or  degeneration  affecting  the  same  regions  of  the  cord 
produces  the  form  of  paralysis  known  as  progressive 
muscular  atrophy,  which  is  most  frequently,  but  not 
exclusively,  bilateral.  When  the  cranial  nerve  nuclei 
(chiefly  those  in  the  medulla)  suffer  from  a  similar 
disease,  the  symptoms  of  bulbar  paralysis  are  produced 
— that  is,  interference  with  the  movements  of  the 
tongue,  palate,  pharynx,  and  larynx.  When  this  form 
of  paralysis  is  due  to  lesion  of  the  peripheral  nerves 
arising  from  the  medulla,  the  loss  of  power  may  be 
one-sided;  if  bilateral,  it  is  termed  " pseudo-bulbar 
paralysis." 

Paralysis  restricted  to  one  or  more  groups  01  muscles, 


122  SYSTEMATIC  CASE-TAKING 

or  even  to  one  muscle,  is  usually  the  result  of  disease 
of  the  peripheral  nerves,  but  may  be  due  to  the  selective 
action  of  morbid  processes  whereby  the  nuclei  of  origin 
of  the  nerves  are  individually  affected.  Less  frequently 
a  restricted  paralysis  is  the  result  of  a  supranuclear 
lesion,  such  as  a  haemorrhage,  softening,  or  tumour, 
involving  a  limited  number  of  fibres  proceeding  from  the 
cortex  to  the  lower  centres  or  nuclei. 

Oculo-motor  paralysis  is  shown  by  loss  of  power  in 
the  movements  of  the  eye  and  of  the  upper  lid  (third, 
fourth,  and  sixth  cranial  nerves).  Determine  in  which 
direction  and  in  which  eye  the  movements  are  defective. 
Note  if  either  upper  lid  droops  {ptosis).  Observe  if  the 
visual  axes  remain  parallel,  or  if,  on  the  contrary,  they 
converge  or  diverge  (convergent  or  divergent  squint  or 
strabismus).  Cover  the  sound  eye,  and  tell  the  patient 
to  endeavour  to  look  steadily  at  an  object  with  the 
affected  eye  ;  in  oculo-motor  paralysis  the  squint  is 
increased  {secondary  deviation).  In  paralytic  squint 
double  vision  is  common  ;  in  the  sound  eye  the  imsige 
falls  on  the  macula  lutea,  and  is  therefore  more  distinct 
{true  image)  than  that  which  falls  on  another  portion 
of  the  retina  of  the  paralyzed  eye  {false  image).  The 
respective  positions  of  the  true  and  false  images  as  seen 
by  the  patient  serve  to  determine  which  of  the  muscles 
is  at  fault. 

Conjugate  Deviation. — Both  eyes  are  turned  to  one 
side,  without  squinting,  and  the  head  is  often  turned 
in  the  same  direction.  This  paralysis  means  a  lesion 
of  the  sixth  nerve  on  one  side  (external  rectus)  and  of  the 
association  fibres  from  the  nucleus  of  the  third  on  the 
other  side,  controlling  the  internal  rectus.  If  the  lesion 
be  in  the  pons  {e.g.,  haemorrhage),  injuring  the  nucleus 
of  the  sixth,  the  eyes  turn  away  to  the  side  opposite 


NERVOUS  SYSTEM  123 

the  lesion.  Should  the  injury  be  supranuclear,  before 
decussation  has  taken  place  the  eyes  will  look  toward 
the  lesion.  If  the  injury  should  be  cortical,  a  stimula- 
tion of  the  opposite  sixth  nerve  may  result,  instead  of 
a  paralysis,  and  the  eyes  will  look  away  from  the 
lesion. 

Lower  Jaw  Paralysis  (fifth  cranial  nerve). — The  tem- 
poral, masseter,  and  pterygoid  muscles  have  lost  tone 
and  power.  On  depressing  the  jaw  it  is  deviated  to  the 
paralyzed  side. 

Facial  Paralysis  (seventh  cranial  nerve). — The  af- 
fected side  is  less  marked  by  skin  folds,  and  is  in  conse- 
quence expressionless.  Direct  the  patient  to  frown, 
raise  his  eyebrows,  tightly  close  his  eyes,  blow  out  his 
cheeks,  whistle,  draw  back  the  corners  of  his  mouth  to 
show  his  teeth.  When  (as  is  often  the  case)  this  para- 
lysis is  part  of  the  result  of  a  supranuclear  lesion,  the 
paralysis  is  less  marked  in  the  upper  than  in  the  lower 
half  of  the  face.  This  is  due  to  the  bilateral  innervation 
which  is  believed  to  be  supplied  to  those  regions  which 
are  habitually  used  in  concert  with  their  fellows  of  the 
opposite  side  of  the  body  {Broadbent's  law).  In  cases  of 
peripheral  seventh  nerve  disease  the  patient  is  unable 
to  close  his  affected  eye,  and  on  endeavouring  to  do  so 
the  eye  rolls  up  under  the  upper  lid  i Bell's  phenomenon). 
Weakness  of  the  cheek  muscles  causes  difficulty  in 
mastication,  and  speech  may  be  indistinct.  Lesions  of 
the  nerve  in  the  bony  canal  may  cause  loss  of  the  taste 
sense  in  the  anterior  half  of  the  tongue  and  diminution 
of  the  secretion  of  saliva,  owing  to  injury  to  the  chorda 
tympani. 

Sterno-mastoid  paralysis  (eleventh  cranial  nerve)  causes 
difficulty  in  turning  the  head  to  the  sound  side.  The 
upper  half  of  the  trapezius  is  supplied  by  the  same  nerve 


124  SYSTEMATIC  CASE-TAKING 

and  is  paralyzed  by  its  lesions  ;  the  point  of  the  shoulder 
is  lowered,  and  the  inferior  angle  of  the  scapula  ap- 
proaches the  spine  ;  there  is  difficulty  in  raising  the  arm 
above  the  level  of  the  head. 

Diaphragm  paralysis  occurs  as  a  result  of  disease  or 
injury  to  the  phrenic  nerve  (third  and  fourth  cervical 
nerves). 

During  deep  inspiration  the  epigastrium  is  observed 
(by  inspection  and  palpation)  to  fall  inwards  when  the 
diaphragm  is  paralyzed.  In  health  it  bulges  forward 
as  the  ribs  rise  during  inspiration.  In  Chapter  VII.  a 
variety  of  causes  for  immobility  of  the  diaphragm  are 
enumerated. 

Paralysis  of  the  arm,  from  injury  to  the  brachial 
plexus,  may  involve  aU  the  muscles  of  the  limb.  The 
deltoid,  biceps,  brachialis  anticus,  and  supinator  longus, 
may  be  paralyzed  {Erb's  paralysis)  by  injury  to  the  fifth 
and  sixth  cervical  nerves.  Serratus  magnus  paralysis 
(long  thoracic  nerve,  fifth  and  sixth  cervical)  prevents 
the  proper  apposition  of  the  scapula  to  the  thorax.  On 
raising  the  arm  with  a  pushing  action,  the  inferior  angle 
of  the  shoulder-blade  is  rotated  backward,  while  the 
bone  projects  like  a  wing.  Deltoid  paralysis  results  from 
lesions  of  the  circumflex  nerve  ;  the  arm  is  raised  with 
difficulty.  Paralysis  of  the  hand;  inability  to  oppose 
the  thumb  to  the  tips  of  the  fingers  [ape-hand),  to  flex 
the  first  row  of  interphalangeal  joints,  or  the  second 
row  of  the  first  and  second  fingers,  together  with  imper- 
fect pronation  of  the  forearm  and  flexion  of  the  wrist 
toward  the  radial  side.  This  paralysis  is  due  to  lesion 
of  the  median  nerve  ;  the  usual  wasting  due  to  lower 
neuron  lesions  causes  the  characteristic  appearance  of 
the  hand.  Lesion  of  the  ulnar  nerve  produces  the 
following  paralysis  :  Abduction  of  the  thumb  ;  defective 


NERVOUS  SYSTEM  125 

lateral  movements  of  the  fingers,  the  hand  being  flat  ; 
extension  of  the  metacarpo-phalangeal  joints  ;  imperfect 
extension  of  the  two  distal  sets  of  phalanges,  especially 
those  of  the  ring  and  little  finger  ;  the  wrist  cannot  be 
flexed  toward  the  ulnar  side.  When  this  condition  has 
existed  for  some  time,  the  wasting  and  deformity  pro- 
duces the  condition  known  as  claw-hand. 

Paralysis  of  the  adductors  of  the  thigh  (inability  to 
cross  the  legs),  from  lesion  of  the  obturator  nerve  ;  this 
may  occur  during  parturition.  Inability  to  extend  the 
knee,  with  loss  of  knee-jerks,  results  from  lesion  of  the 
anterior  crural  nerve.  Paralysis  of  the  hamstring  muscles 
and  of  the  leg  below  the  knee  follows  injury  or  disease 
of  the  sciatic  nerve  ;  this  sometimes  arises  in  the  pelvis 
(tumours,  parturition),  or  the  nerve  may  be  damaged 
at  the  hip  or  thigh. 

(2)  Increased  Involuntary  Movements  of  various  de- 
scriptions are  observed  in  certain  affections  of  the  nervous 
system,  and  are  spoken  of  as  spasm.  They  may  take 
the  form  of  (i.)  continuous  or  tonic  spasm  ;  and  (ii.)  inter- 
rupted or  clonic  spasm. 

The  cause  of  increased  muscular  action  is  an  irritation 
of  the  motor  tract  by  a  lesion  or  disorder,  which  may 
be  of  the  same  nature  as  those  which  have  been  already 
referred  to  as  producing  destruction  of  the  motor  tract. 
Indeed,  the  two  conditions  of  paralysis  and  spasm  may 
be  found  in  the  same  patient  for  this  reason ;  the 
ordinary  spastic  paralysis,  however,  is  the  result  of  a 
destructive  lesion  of  the  motor  tract,  together  with 
exaltation  of  the  reflexes,  and  not  irritation  of  the 
motor  centres. 

Irritation  of  the  nerve  roots  is  less  frequently  a  cause 
of  spasm,  and  hysteria  is  not  unusual  as  the  chief  factor 
in  spasmodic  affections. 


126  SYSTEMATIC  CASE-TAKING 

(i.)  Tonic  spasm  produces  a  rigidity  of  the  limb  or 
group  of  muscles  affected.  The  following  instances  may 
be  noted : 

Trismus,  spasm  of  the  muscles  of  mastication,  occurs 
early  in  tetanus  and  late  in  strychnine-poisoning.  The 
risus  sardonicus  of  these  two  diseases  is  a  spasm  of  the 
facial  muscles,  and  tonic  spasms  of  the  muscles  of  the 
trunk  and  limbs  occur  in  the  same  affections,  to  which  the 
following  descriptive  names  have  been  given  :  Opistho- 
tonos, muscles  of  the  back,  causing  backward  curving 
of  the  body  ;  emprosthotonos,  forward  curving  ;  pleuros- 
thotonos,  curving  to  one  side  ;  orthotonos,  the  body  re- 
maining straight  and  rigid. 

A  tonic  spasm  of  the  arms  and  legs,  known  as  tetany, 
consists  in  flexion  of  the  wrist  and  metacarpo-phalangeal 
joints,  extension  of  the  finger- joints,  and  the  thumb 
adducted  across  the  palm  ;  elbow  flexed  ;  leg  and  foot 
extended,  and  toes  flexed.  When  tetany  is  present,  if 
the  facial  nerve  is  struck  just  in  front  of  the  ear,  the 
facial  muscles  contract  {Chvostek's  sign),  and  the  motor 
nerves  generally  are  unusually  sensitive. 

Torticollis,  a  spasm  chiefly  of  the  sterno-mastoid,  tonic 
as  a  rule,  but  sometimes  clonic. 

Retraction  of  the  head,  owing  to  spasm  of  the  posterior 
cervical  and  dorsal  muscles,  occurs  as  a  result  of  intra- 
cranial irritation,  commonly  found  in  cerebral  menin- 
gitis. In  this  disease  spasm  of  the  hamstring  muscles 
is  often  found ;  the  hip- joint  should  be  well  flexed,  and 
in  cases  of  meningitis  it  is  found  impossible  to  straighten 
the  leg  at  the  knee  {Kernig's  sign). 

A  tonic  spasm  occurs  in  muscles  which  have  been 
overworked,  and  is  most  common  in  the  hand.  It  is 
known  as  professional  spasm  or  occupation  neurosis,  and 
occurs  as  a  cramp-like  contraction  of  the  muscles  on 


NERVOUS  SYSTEM  127 

attempting  to  use  the  hand.     Sometimes  a  trembling  and 
weakness  is  found  instead  of  spasm. 

(ii.)  Clonic  spasms  are  seen  as  intermittent  contrac- 
tions of  muscle  groups  ;  the  force,  frequency,  and  regu- 
larity of  recurrence  of  the  contractions  may  be  observed 
in  all  degrees  of  difference  from  the  finest  tremor  to  the 
most  violent  convulsion. 

The  finest  movements  of  this  description  are  fibrillary 
fwitchings  of  very  small  bundles  of  muscle  fibres,  seen 
in  wasting  diseases.  Tremor  is  the  regular  clonic  spasm, 
which  is  sufficiently  ample  to  move  the  limb.  In  some 
conditions  [e.g.,  paralysis  agitans)  it  is  worst  while  the 
limb  is  at  rest.  In  other  cases  (e.g.,  disseminate  sclerosis) 
the  trembling  becomes  more  marked  as  the  patient  tries 
to  control  it  in  order  to  perform  some  purposeful  move- 
ment [intention  tremor).  Tremor  is  a  familiar  symptom 
in  functional  nervous  disturbances  (hysteria,  emotions) ; 
it  is  caused  by  exposure  to  cold ;  a  fine  tremor  is  found 
in  exophthalmic  goitre.  A  tremor  of  the  lips  and 
tongue  is  seen  in  general  paralysis  of  the  insane  and  in 
alcoholism. 

Rigors  are  a  rather  coarser  tremor,  involving  most  of 
the  muscles  of  the  body.  They  occur  in  fevers  of  some 
severity. 

A  regularly  recurring  clonic  spasm  of  the  ocular 
muscles  is  termed  nystagmus.  On  causing  the  patient 
to  turn  his  eyes  strongly  to  one  side,  the  head  being 
maintained  steady,  movements  of  the  eyeball,  about  two 
or  three  per  second,  are  observed.  They  are  usually  in  a 
lateral  direction,  but  are  occasionally  upward  or  down- 
ward. It  is  chiefly  in  multiple  sclerosis  that  nystagmus 
is  seen,  but  it  occurs  in  cases  of  cerebellar  disease,  Fried- 
reich's ataxia,  in  cerebral  haemorrhage,  and  in  some  other 
rarer  affections  of  the  nervous  system.  In  addition,  defects 


128  SYSTEMATIC  CASE-TAKING 

of  sight  from  disease  or  injury  of  the  eye  are  a  common 
cause.  Of  this  nature  is  miner's  nystagmus,  due  to  the 
continuous  use  of  the  eyes  in  a  constrained  position  in 
bad  light. 

Irregular  forcible  contractions  occur  under  a  variety 
of  circumstances,  and  from  their  resemblance  to  idio- 
pathic epilepsy  are  grouped  together  as  epileptiform 
attacks  or  convulsive  fits.  The  latter  name  should  be 
reserved  for  convulsive  attacks  accompanied  by  uncon- 
sciousness. The  conditions  which  are  likely  to  produce 
these  clonic  spasms  belong  to  three  classes  :  (i)  Cortical 
disease  or  injury  (Jacksonian  epilepsy)  ;  (2)  toxic  condi- 
tions of  the  blood,  causing  irritation  of  the  motor  centres 
(uraemia,  puerperal  eclampsia,  diabetes,  asphyxia, 
opium-poisoning,  etc.) ;  (3)  convulsive  attacks  without 
known  lesions  (hysteria,  idiopathic  epilepsy,  infantile 
convulsions,  chorea,  and  a  variety  of  choreiform  affec- 
tions). 

(3)  Disorderly  Movements. — Normal  power  of  muscular 
contraction  is  of  little  use  if  the  muscles  do  not  act 
properly  in  harmony.  Want  of  concerted  contractions 
produces  irregular  and  badly-directed  movements  of 
the  affected  limbs,  the  condition  being  known  as  ataxia, 
or  inco- ordination.  In  health  the  individual  is  conscious, 
without  the  aid  of  sight,  of  the  position  of  his  limbs, 
and,  owing  to  the  information  conveyed  to  his  sensorium, 
he  knows  the  amount  of  energy  that  is  expended  in  any 
muscular  action.  It  is  this  strength  sense,  or  innervation 
sense,  which  is  the  chief  factor  in  producing  co-ordinated 
movements  of  the  body. 

In  order  to  test  co-ordination,  the  patient  is  directed 
to  perform  a  variety  of  actions  without  the  aid  of 
sight.  He  is  to  stand,  turn,  walk,  with  his  eyes  open 
and  then  closed  ;  inability  to  maintain  his  balance  while 


NERVOUS  SYSTEM  129 

standing  with  closed  eyes  is  known  as  Romberg's  sign. 
Want  of  neatness  and  accuracy  in  the  various  movements 
is  to  be  noted.  This  is  best  marked  when  the  eyes  are 
closed.  Thus,  he  may  be  directed  to  touch  the  tip  of 
his  nose  with  his  forefinger,  or  bring  the  forefinger  of 
each  hand  together,  the  eyes  being  closed.  The  legs 
may  be  tested  by  requesting  him  to  describe  circles  or 
other  figures  in  the  air,  or  on  the  floor,  with  his  great- 
toe,  to  touch  certain  spots  with  his  toe  or  heel,  to  walk 
along  a  board  or  follow  a  pattern  in  the  carpet,  etc. 
His  mode  of  progression,  or  gait,  is  to  be  observed ;  it 
may  be  stamping,  reeling,  or  stumbling. 

Inco-ordination  is  found  in  (i)  lesions  of  the  posterior 
columns  of  the  cord,  of  which  locomotor  ataxia  is  the 
commonest  example  ■  (2)  lesions  of  the  cerebellum  ; 
(3)  disease  of  the  semicircular  canals  and  vestibular 
nerves  causes  an  ataxia  similar  to  that  of  cerebellar 
disease  (vertigo),  and,  when  accompanied  by  vomiting, 
deafness,  faintness,  and  other  symptoms,  is  known  as 
Meniere's  disease — irritation  in  the  external  or  middle  ear 
is  a  common  cause  of  vertigo  ;  (4)  other  cerebral  lesions, 
especially  those  of  the  parietal  lobes,  cause  a  form  of 
ataxia  ;  (5)  lastly,  peripheral  nerve  lesions  may  produce 
a  condition  closely  resembling  inco-ordination. 

2.  Reflexes. — Certain  muscular  contractions  occur  inde- 
pendently of  volition  ;  their  normal  occurrence  depends 
on  the  integrity  of  a  reflex  arc,  consisting  of  a  sensory 
nerve,  a  motor  centre  (in  the  anterior  cornua,  medulla, 
pons,  or  crura),  and  an  efferent  nerve  with  its  muscle. 
It  is  by  a  mechanism  of  this  nature  that  the  normal 
tone  of  muscles  is  maintained.  It  is  found  that  the 
activity  of  the  reflex  acts  is  modified  and  controlled  by 
nerve  impulses  descending  to  the  reflex  arc  from  higher 
cerebral  centres.    Owing  to  interruption  in  these  con- 

9 


I30  SYSTEMATIC  CASE-TAKING 

trolling  or  inhibiting  pathways,  such  as  occurs  in  supra- 
nuclear lesions  in  the  brain  and  cord,  the  exaggerated 
reflexes  occurring  in  spastic  paralysis  take  place.  There 
are  other  causes  for  increased  reflex  activity,  such  as  the 
effects  on  the  cord  of  the  poison  of  tetanus,  of  hydro- 
phobia, of  strychnia,  etc.  ;  the  influence  of  emotional 
stimulation  is  seen  in  the  exaggerated  reflexes  of 
hysteria. 

By  stimulating  the  reflex  arc,  certain  movements  of 
the  region  are  caused,  and  departures  from  the  normal 
occurrence  of  these  movements  are  to  be  noted.  We 
must  compare  the  resulting  reflex  movements  with  what 
we  regard  as  normal,  and  also  compare  the  movements 
on  opposite  sides  of  the  body. 

There  are  three  groups  of  reflexes  to  be  observed  : 
(i)  Deep  or  tendon  reflexes ;  (2)  skin  reflexes ;  and  (3) 
visceral  reflexes. 

(i)  Deep  or  tendon  reflexes  are  elicited  by  suddenly 
stretching  still  further  a  muscle  which  has  already  been 
put  on  the  stretch.  The  most  useful  example  is  the 
knee-jerk  or  patellar  reflex.  The  patient  is  seated,  if 
possible,  with  his  bent  leg  supported  on  the  observer's 
hand ;  a  sharp  blow  is  struck  on  the  patellar  tendon, 
causing  the  extensors  of  the  knee  to  contract,  with  brisk 
extension  of  the  limb  at  the  joint.  This  reaction  may 
be  rendered  more  obvious  by  distracting  the  patient's 
attention  ;  thus,  he  should  grip  his  hands  and  pull  as  if 
drawing  them  apart,  his  eyes  meanwhile  being  directed 
to  the  ceiling.  The  knee-jerk  is  usually  present  in 
health  ;  its  absence  is  known  as  Westphal's  sign,  and 
may  be  an  evidence  of  lesion  of  the  reflex  arc  (locomotor 
ataxia,  neuritis,  etc.).  Patellar  clonus  is  an  intermittent 
or  clonic  contraction  of  the  extensors  of  the  leg,  when 
they  have  been  suddenly  stretched  by  quickly  forcing 


NERVOUS  SYSTEM  131 

downward  the  patella,  the  leg  being  fully  extended. 
It  is  only  found  when  the  knee-jerk  is  exaggerated. 
Ankle  clonus  is  a  rhythmical  contraction  of  the  calf 
muscles,  observed  in  conditions  of  exalted  reflexes ; 
it  is  demonstrated  by  putting  the  muscles  in  question 
on  the  stretch  by  pressure  on  the  sole  of  the  foot,  causing 
the  foot  to  be  flexed  dorsally.  This  may  be  enough 
to  produce  the  clonus,  but  it  is  usually  necessary  to  give 
a  stimulus  by  sudden  pressure  on  the  sole,  further  in- 
creasing the  flexion  of  the  foot.  This  phenomenon  is 
rarely  found  in  health.  A  single  jerk  [ankle-jerk)  on  strik- 
ing the  tendo  Achillis  is  similarly  a  sign  of  increased 
reflexes. 

Arm-jerks  may  be  found  at  times  in  health,  but  are 
usually  an  evidence  of  excessive  reflex  activity.  The 
following  may  be  mentioned  :  Wrist-jerk :  a  tap  on  the 
extensor  tendons  just  above  the  wrist  causes  the  hand 
to  be  extended.  Elbow- jerk,  an  extension  of  the  bent 
forearm  on  striking  the  triceps  tendon  just  above  the 
joint ;  a  flexion  of  this  joint  may  also  be  obtained  by 
striking  the  biceps  or  supinator  longus  tendons.  Scapulo- 
humeral reflex,  an  external  rotation  of  the  arm  on  striking 
the  spinal  border  of  the  scapula ;  when  the  reflex  is  ex- 
aggerated more  extensive  motions  of  the  arm  occur. 

Jaw-jerk,  not  usually  found  in  health.  The  patient's 
mouth  being  open,  one  finger  of  the  observer  is  placed, 
pleximeter  fashion,  on  the  chin,  and  a  downward  stroke 
is  given  with  the  finger  of  the  other  hand ;  an  upward 
jerk  of  the  jaw  follows,  and  if  pressure  be  kept  up  clonic 
contractions  may  occur. 

(2)  Skin  or  superficial  reflexes  are  of  less  diagnostic 
value,  as,  with  the  exception  of  the  dorsal  flexion  of  the 
toe,  their  occurrence  is  uncertain  in  health  and  disease. 
They  are  useful  at  times  in  estimating  the  level  at  which 


132  SYSTEMATIC  CASE-TAKING 

spinal  disease  has  occurred,  and  their  occurrence  on 
each  side  of  the  body  should  be  tested  and  compared. 
They  are  obtained  by  stroking  or  gently  irritating  or 
pricking  or  pinching  the  skin,  and  noting  if  the  appro- 
priate movement  takes  place. 

Plantar  reflex  is  shown  by  involuntary  drawing  up  of 
the  limb  ;  in  cases  of  exaggerated  reflexes  this  movement 
is  increased  in  activity,  and  in  addition  there  may  be 
dorsal  flexion  of  the  great-toe,  the  other  toes  being  flexed 
towards  the  sole  of  the  foot  {Babinski's  sign) .  In  a  normal 
state  of  the  reflexes  all  the  toes  are  flexed  toward  the 
sole  of  the  foot,  except  in  infants  who  have  not  learned 
to  walk,  and  with  whom  dorsal  flexion  of  the  great  toe 
is  the  rule.  Cremaster  reflex :  drawing  up  of  the  testicle 
on  stimulating  the  skin  of  the  inner  and  upper  part  of 
the  thigh.  Inguinal  reflex :  a  similar  stimulus  causes 
contraction  of  some  of  the  fibres  of  the  internal  oblique 
muscle  near  Poupart's  ligament.  Abdominal  reflexes  axe 
contractions  of  portions  of  the  oblique  and  recti  muscles 
on  stroking  the  side  of  the  abdomen  and  lower  part  of 
the  thorax  (epigastric,  umbilical,  and  hypogastric  re- 
flexes). Gluteal  reflex:  contraction  of  the  glutei  follow- 
ing irritation  of  the  skin  over  the  buttocks. 

Corneal  reflex  :  closure  of  eyelids  on  gently  touching 
the  cornea.  Palatal  reflex  :  the  soft  palate  rises  on  being 
touched.  Pharyngeal  reflex  :  retching  caused  by  tickling 
the  fauces. 

(3)  Visceral  or  complex  reflexes,  by  which  the  efficiency 
of  certain  organs  is  assisted,  maybe  disturbed  in  disease, 
and  in  some  instances  their  disorders  may  be  of  diagnostic 
importance. 

Pupil  Reflex. — Observe  the  behaviour  of  each  pupil 
separately  when  exposed  to  varying  amounts  of  light. 
On  light  being  suddenly  admitted  to  a  normal  eye,  the 


NERVOUS  SYSTEM  133 

pupil  contracts  forcibly,  then  slightly  relaxes  and  again 
contracts  ;  this  oscillation  of  the  pupil,  termed  hippus, 
is  slight  in  health,  but  in  conditions  of  exaggerated 
reflexes  it  may  be  quite  obvious.  A  reflex  dilatation 
of  the  pupil  to  painful  stimuli  is  also  obtainable  by 
pinching  or  pricking  the  skin  of  the  neck,  and  at  times 
by  painful  impressions  from  any  part  of  the  body.  A 
contraction  of  the  pupil  also  occurs  on  focussing  the 
eyes  to  close  vision,  this  being  due  to  muscular  effort 
of  the  muscles  concerned  in  accommodation.  Absence 
of  light  reflex  with  persistence  of  accommodation  con- 
traction (the  Argyll-Robertson  pupil)  is  found  in  loco- 
motor ataxia  and  general  paralysis  of  the  insane. 

The  light  reflex  is  absent  in  conditions  of  deep  un- 
consciousness, in  poisoning  by  belladonna,  hyoscyamine, 
cocaine,  etc.  ;  in  paralysis  of  the  third  nerve  ;  in  intra- 
cranial lesions  interrupting  the  pupil  reflex  arc  ;  and  in 
loss  of  perception  of  light. 

Bladder  and  rectum  reflexes  are  at  times  disturbed  by 
disease.  The  functions  of  these  organs  are  largely 
carried  out  by  a  series  of  reflexes  ;  the  retention  by  a 
sphincter  and  the  expulsion  by  detrusor  muscle  fibres 
of  their  contents  are  mainly  involuntary  and  reflex  acts. 
The  reflex  arcs  have  their  centres  in  the  lumbar  portion 
of  the  cord  ;  damage  to  this  region,  or  the  portions  of 
the  cord  higher  up,  may  result  in  incontinence  or  ob- 
struction of  urine  or  faeces. 

Vasomotor  Reflex. — ^The  proper  supply  of  blood  to 
the  different  organs  and  regions  of  the  body,  in  accord- 
ance with  their  needs,  is  maintained  by  a  reflex  mechan- 
ism, acting  chiefly  on  the  muscular  coats  of  the  small 
arteries.  The  diagnostic  interest  of  disturbances  of 
this  reflex  are  not  great.  The  appearance  of  bright  red 
marks,  and  even  raised  oedematous  patches,  where  the 


134  SYSTEMATIC  CASE-TAKING 

skin  was  irritated  by  rubbing  gently  [tache  cerehrale  or 
spinale,  also  known  as  dermographism)  is  sometimes 
found  in  meningitis  and  diseases  of  the  brain  and  cord. 
Erection  of  the  penis  {priapism),  a  result  of  vasomotor 
disturbance,  occurs  in  lesions  of  the  cord  and  medulla. 
Other  examples  of  visceral  reflexes,  such  as  coughing, 
vomiting,  hiccough,  do  not  require  further  mention 
here. 

3.  Sensory  Functions. — ^Afferent  nerve  impulses  from 
sensitive  organs  in  the  periphery  give  rise  to  (i)  tactile 
and  pressure  sensibility ;  (2)  pain  ;  (3)  thermal  sensi- 
bility ;  (4)  sense  of  strength  or  innervation  ;  (5)  sense 
of  movement  or  position  ;  (6)  sense  of  shape  or  form  ; 
(7)  special  senses  of  sight,  hearing,  taste,  and  smell. 

(i)  Tactile  sensibility  is  tested  by  directing  the 
patient  to  say  *'  now  "  the  moment  he  feels  a  light 
touch,  his  eyes  being  closed.  A  piece  of  cotton-wool 
or  a  camel's-hair  brush  should  be  used,  so  that  pressure 
is  avoided.  In  order  to  test  his  power  of  locating  the 
stimulus,  he  may  be  told  to  point  to  the  spot  touched. 
His  ability  to  distinguish  when  he  is  touched  in  two 
places  close  together  may  be  used  as  a  measure  of  the 
acuteness  of  his  common  sensation.  For  this  purpose 
the  points  of  a  pair  of  compasses  or  scissors  may  be 
applied  gently  to  the  skin,  and  the  shortest  distance 
between  the  points  at  which  he  can  recognize  two  points 
of  contact  should  be  noted.  An  instrument  (sesthesio- 
meter)  is  made  for  this  purpose.  Pressure  sensibility 
is  a  form  of  tactile  sensibility,  and  is  tested  by  placing 
objects  of  the  same  size  but  of  different  weight  on  the 
surface,  the  limb  being  supported  so  as  to  obviate 
muscular  effort ;  the  patient  is  to  state  which  object  is 
the  heaviest. 

Any  obstruction  in  the  path  of  afferent  nerve  im- 


NERVOUS  SYSTEM  135 

pulses  will  result  in  more  or  less  complete  loss  of  common 
sensation  {ancesthesia).  This  symptom  is  often  a  help 
in  locating  the  situation  of  such  an  obstructing  lesion. 
In  neurotic  states  anaesthesia  is  common,  but  without 
anatomical  consistency. 

An  undue  sensitiveness  of  the  organs  concerned  in  the 
perception  of  tactile  stimuli  may  give  rise  to  excessive 
acuteness  of  the  sense  of  touch  [hyper cesthesia)  ;  abnormal 
sensations  (paresthesia)  may  be  perceived,  such  as 
tingling,  tickling,  cotton-wool  feeling,  crawling  of 
insects  (formication) ;  a  single  stimulus  may  give  rise 
to  several  tactile  impressions  (polycesthesia) ;  the  patient 
may  be  unable  to  localize  pain  or  touch  sense  (allocheiria). 

(2)  Pain. — ^The  inability  to  recognize  painful  stimula- 
tion may  be  diminished  or  lost  (analgesia),  or  may  be 
intensified  (hyperalgesia).  The  former  is  tested  by 
pricking  or  pinching  the  skin,  noting  if  the  patient 
shows  any  sign  of  suffering  ;  the  latter  by  rubbing  a 
blunt  instrument  (e.g.,  the  head  of  a  pin)  firmly  in 
parallel  lines  over  the  surface,  or  by  pressure  of  the 
hand.  Should  hyperalgesia  be  present,  the  patient  will 
be  able  to  indicate  the  position  where  the  friction  or 
pressure  causes  pain  instead  of  mere  tactile  sensibility. 

Loss  of  the  sense  of  pain  usually  accompanies  loss  of 
tactile  sensibility,  but  in  cases  of  syringomyelia  the  pain- 
ful impulses  (as  well  as  those  of  heat  and  cold)  are  ob- 
structed by  the  disease  of  the  central  canal,  while  those 
of  common  sensation  passing  upward  through  the  pos- 
terior columns  are  less  interrupted.  The  loss  of  painful 
and  thermal  sensibility,  with  the  retention  of  touch 
sense,  is  termed  dissociated  ancesthesia. 

Increased  sensibility  to  pain  may  be  found  in  lesions 
of  the  spinal  cord  and  its  meninges,  whereby  the  pos- 
terior nerve  roots  are  irritated.     As  a  result  there  may 


136  SYSTEMATIC  CASE-TAKING 

be  a  zone  of  hyperalgesia,  or  hypersesthesia,  at  the  level 
of  the  injured  segment  of  the  cord  (girdle  fain).  Other 
examples  of  hyperalgesia  may  be  observed,  by  similar 
means  to  that  mentioned  above,  in  certain  cases  of 
internal  disorders,  in  which,  as  mentioned  in  Chapter  I., 
the  visceral  pain  is  referred  to  a  spot  on  the  surface, 
owing  to  the  proximity  in  the  cord  of  the  afferent  nerve 
paths  from  the  respective  regions. 

(3)  Sensibility  to  heat  and  cold  may  be  tested  by 
touching  the  patient's  skin  with  test-tubes,  one  filled 
with  hot  and  the  other  with  cold  water.  In  syringo- 
myelia dissociated  anaesthesia  frequently  occurs ;  the  heat 
sense  may  be  absent  in  multiple  sclerosis,  in  locomotor 
ataxia,  and  in  hysteria. 

(4)  Sense  of  strength  or  of  innervation  is  tested  by 
adding  weights  to  or  taking  them  from  a  sling  suspended 
by  a  broad  band  from  the  hand  ;  the  patient  is  to  say 
when  he  notices  differences  in  the  weight.  The  muscular 
power  employed  can,  with  practice,  be  accurately  judged 
by  healthy  persons,  but  in  conditions  of  inco-ordination 
the  judgment  is  defective. 

(5)  Muscle  sense  or  sense  of  movement  and  position  is  a 
combination  of  the  innervation  sense  with  tactile  sensi- 
bility (skin,  joint  surfaces,  etc.).  Direct  the  patient  to 
perform  a  number  of  movements  of  the  limbs  with  the 
eyes  closed ;  he  is  then  to  describe  the  position  of  his 
limbs  without  having  looked  at  them. 

This  sense,  like  the  strength  sense,  is  disturbed  in 
ataxic  conditions. 

(6)  Stereognosis,  or  judgment  of  shape,  form,  and 
character  of  an  object,  is  produced  by  a  combination 
of  the  perceptions  of  touch,  temperature,  and  muscular 
action. 

(7)  The  organs  of  special  sense  are  to  be  examined 


NERVOUS  SYSTEM  i37 

with  regard  to  the  state  of  the  nervous  system,  and  not 
to  local  disease  in  the  organ,  for  which  the  reader  must 
consult  special  textbooks. 

Vision.— The  patient's  distinctness  of  visual  percep- 
tion is  first  to  be  investigated,  both  for  distant  and  for 
near  objects.  The  conditions  which  give  rise  to  dimness 
of  vision  (apart  from  local  eye  affections)  are  mainly 
optic  neuritis  and  optic  atrophy  ;  the  latter  always,  and 
the  former  sometimes,  causes  defective  sight. 

The  ophthalmoscopic  examination  is  next  to  be  made. 
The  following  abnormalities  having  reference  mainly  to 
nervous  diseases  may  be  observed  : 

(i)  Optic  Neuritis. — The  disc  is  swollen  and  red,  its 
margins  indistinct,  the  central  vein  larger  than  normal, 
while  the  central  artery  is  of  normal  size  or  contracted. 
In  extreme  cases  papillitis  or  choked  disc  occurs — that  is, 
the  papilla  projects  as  a  dome-shaped  elevation,  and 
white  striae  or  spots  may  surround  it,  while  flame-shaped 
patches  are  seen  near  and  on  the  papilla.  The  cause 
of  optic  neuritis  is  most  frequently  tumour  or  abscess  of 
the  brain,  also  meningitis  and  hydrocephalus.  Occa- 
sionally it  occurs  in  spinal  disease — viz.,  tabes  dorsalis 
and  myelitis ;  also  rarely  in  peripheral  neuritis.  It  may 
be  due  to  tumour  or  inflammation  of  the  orbit.  In 
certain  toxic  states  of  the  blood,  in  which  the  central 
nervous  system  is  not  primarily  at  fault,  optic  neuritis 
also  occurs — e.g.,  chlorosis,  rheumatism,  lead-poisoning, 
Bright's  disease,  syphilis. 

(2)  Optic  Atrophy. — ^The  disc  is  pale,  hollowed  on  the 
surface  {cupped),  the  vessels  shrunken,  and  often  out- 
lined by  two  white  lines  representing  their  thickened 
coats.  It  may  be  a  primary  disease  of  the  nerve,  or 
may  be  secondary  to  lesion  in  the  nerve  or  brain.  Sight 
is  affected  in  proportion  to  the  extent  of  the  atrophy. 


13^  SYSTEMATIC  CASE-TAKING 

(i.)  Primary  optic  atrophy  occurs  in  locomotor  ataxia 
most  commonly,  less  frequently  in  multiple  sclerosis  and 
general  paralysis  of  the  insane.  It  is  also  believed  to  be 
due  to  exposure  to  cold,  sexual  excess,  diabetes,  lead- 
poisoning,  and  alcoholism. 

(ii.)  Secondary  optic  atrophy  may  result  from  optic 
neuritis  ;  from  embolism  of  the  central  artery  of  the 
retina  and  from  retinitis ;  from  intracranial  pressure  of 
tumours,  inflammation  and  haemorrhage. 

(3)  Retinitis. — ^Cloudiness  of  the  fundus  with  enlarged 
veins  ;  hsemorrhagic  patches,  and  white  exudations  and 
degenerations.  If  congestion  of  the  papilla  accompanies 
the  retinitis,  the  condition  is  neuro-retinitis.  It  is  found 
in  the  following  conditions :  Nephritis,  most  frequently 
in  the  contracted  form,  and  in  an  advanced  stage  ; 
cardiac  and  vascular  diseases — e.g.,  valvular  disease, 
arterio-sclerosis,  aneurism  ;  diabetes,  severe  anaemias, 
lead-poisoning,  infectious  diseases.  In  pyaemia  or  septi- 
caemia a  purulent  retinitis  may  occur,  in  which  case 
the  inflammation  may  soon  involve  the  whole  eye 
(panophthalmitis).  In  children  with  defective  develop- 
ment from  hereditary  causes  (e.g.,  syphilis  or  consan- 
guinity of  parents)  pigmented  spots  distributed  towards 
the  periphery  of  the  fundus  and  encroaching  upon  the 
central  regions  may  be  observed. 

(4)  Tumours  of  the  eye  are  only  of  diagnostic  interest 
when  they  indicate  the  nature  of  similar  growths  in  other 
parts  of  the  body.  The  most  important  is  tubercle, 
occurring  as  one  or  more  round  yellowish  spots  in  the 
choroid,  usually  near  the  disc,  and  usually  part  of  a  general 
miliary  tuberculosis. 

Various  minor  disturbances  of  vision  occur;  floating 
spots  and  beaded  threads  [muscce  volitantes)  are  observed 
by  persons  suffering  from  digestive  disturbance,  hysteria. 


NERVOUS  SYSTEM  I39 

cardiac  hypertrophy,  etc.  Yellow  discoloration  of  all 
objects  may  be  noticed  by  jaundiced  patients  and  by 
those  taking  santonin.  Flashes  of  light  occur  in  indi- 
gestion, in  migraine,  and  they  may  form  the  aura  of 
epilepsy.  Dark  patches  with  bright  margins  (glittering 
scotomata)  occur  in  migraine  ;  also  in  irritative  lesions 
of  the  cortex. 

The  Field  of  Vision  is  the  area  within  which,  the  eye 
under  examination  being  fixed  upon  any  point  and  the 
other  eye  being  closed,  white  objects  can  be  distin- 
guished. On  the  temporal  side  of  the  eye  it  reaches 
about  90  degrees,  and  on  the  nasal  side  50  degrees.  At 
one  spot,  the  "  blind  spot,"  15  degrees  to  the  outside  of 
and  a  little  below  the  point  upon  which  the  gaze  is  fixed 
(the  point  of  fixation),  objects  are  invisible.  From  this 
spot  light  passing  through  the  pupil  falls  upon  the 
entering  optic  fibres.  Certain  colours  are  less  easily 
perceived  than  others,  green  being  the  most  difficult  to 
see  in  the  peripheral  regions  of  the  field  of  vision,  and 
blue  the  easiest.  In  order  to  investigate  the  field  of 
vision  an  instrument,  the  perimeter,  is  used,  by  means  of 
which  the  area  visible  to  the  patient  may  be  recorded 
on  a  chart. 

The  patient  may  be  unaware  of  defects  of  the  field 
of  vision  ;  this  is  the  condition  known  as  vision  nulle. 
Vision  obscure  is  a  darkened  or  indistinct  vision,  which 
causes  the  patient  inconvenience.  The  former  is  usually 
caused  by  a  lesion  of  the  vision  centre  in  the  cortex,  while 
the  latter  results  from  a  lesion  lower  in  the  visual  path. 
A  defective  area  in  the  field  of  vision  is  termed  a  scotoma, 
which  may  be  peripheral,  central,  temporal,  or  nasal, 
according  to  its  position.  The  following  defects  in  the 
field  of  vision  may  be  found  : 

(i)  Hemianopsia. — -One -half  of  the  field  is  blind.    This 


I40  SYSTEMATIC  CASE-TAKING 

may  occur  in  one  or  both  eyes  ;  most  commonly  both  eyes 
are  affected.  When  the  blind  halves  of  the  field  are 
both  on  the  same  side  of  the  median  line,  the  condition 
is  termed  homonymous  hemianopsia.  A  lesion  of  the 
optic  path  above  the  chiasma  will  cause  this  defect. 
Loss  of  sight  in  both  the  outer  halves  of  the  field  of 
vision  [bitemporal  hemianopsia)  is  rarer,  and  is  due  to  a 
lesion  of  the  chiasma.  Other  forms  of  hemianopsia 
(unilateral,  bilateral,  nasal,  superior,  and  inferior)  are 
very  rare,  as  they  depend  on  damage  to  a  portion  only 
of  the  fibres  of  the  chiasma. 

The  lesions  causing  hemianopsia  are  usually  organic 
brain  affections,  fractures  of  the  base  of  the  skull,  or 
tumour  of  the  pituitary  body.  Functional  disorders  of 
the  nervous  system,  however,  are  an  occasional  cause — 
e.g.,  hysteria,  migraine,  fatigue,  epilepsy,  digestive  dis- 
turbances. 

(2)  Total  blindness  of  one  eye  alone  is  due  to  a  lesion 
of  the  optic  nerve  (excluding  disease  of  the  eye). 

(3)  Contracted  field  of  vision,  the  peripheral  area  being 
defective,  may  result  from  optic  atrophy,  glaucoma,  and 
functional  disturbances. 

(4)  Central  scotoma,  or  toxic  central  amblyopia,  is  a 
defect  of  vision  in  the  central  part  of  the  field  of  vision,, 
especially  for  colours.  It  is  caused  by  excess  of  tobacco 
and  alcohol ;  also  by  diabetes,  uraemia,  quinine,  iodoform, 
etc. 

Hearing. — Defects  of  this  sense  have  but  little  diag- 
nostic interest,  and  generally  indicate  disease  of  the 
organ  of  hearing.  Psychical  deafness — that  is,  inability 
to  recall  the  meaning  of  well-known  sounds — is  referred 
to  below. 

Imaginary  sounds  are  heard  in  some  mental  diseases, 
and  at  times  in  irritative  lesions  of  the  cortex  of  the 


NERVOUS  SYSTEM  14« 

brain  ;  they  may  form  the  aura  in  cases  of  Jacksonian 
epilepsy. 

Smell. — Loss  of  this  sense  (anosmia),  or  perversions 
of  it,  generally  result  from  local  affections  of  the  nose. 
Occasionally  it  may  be  due  to  lesion  of  the  olfactory 
bulb  or  of  the  intracranial  connections  of  the  nerve,  to 
lesion  of  the  fifth  nerve,  to  degenerative  affections  of 
the  central  nervous  system  [e.g.,  locomotor  ataxia),  or 
it  may  be  a  symptom  of  hysteria. 

Excessive  acuteness  of  the  sense  of  smell  [hyper osmia) 
is  sometimes  a  symptom  of  hysteria. 

Perverted  sense  of  smell  [parosmia)  sometimes  occurs 
in  mental  affections,  and  it  is  not  unusual  for  the  aura  of 
epilepsy  to  assume  this  form. 

To  test  the  sense,  direct  the  patient  to  smell  savoury 
but  non-irritating  substances — e.g.,  oil  of  peppermint, 
assafoetida,  but  not  *'  head-salts "  or  other  form  of 
ammonia — and  see  if  he  can  identify  them. 

Taste. — Deficiency  in  acuteness  [ageusia)  and  per- 
versions [parageusia)  of  the  sense  of  taste  are  observed 
as  a  result  of  affections  of  the  tongue  or  mouth,  and  of 
conditions  which  impair  the  sense  of  smell.  They  are 
less  frequently  due  to  disease  of  the  trigeminal  or  glosso- 
pharyngeal nerves  or  their  central  connections.  Facial 
paralysis  is  often  accompanied  by  partial  and  one-sided 
ageusia,  owing  to  the  implication  of  the  chorda  tympani. 

Parageusia  sometimes  occurs  as  an  epileptic  aura,  and  is 
not  infrequent  in  cases  of  mental  disease  and  in  hysteria. 

In  order  to  test  the  sense  of  taste,  particles  of  sugar, 
common  salt,  or  magnesium  sulphate,  are  placed  on  the 
dorsum  of  the  tongue,  first  on  the  anterior  portion,  then 
on  the  posterior ;  the  tongue  remaining  protruded,  the 
patient  is  to  signify  (in  writing  if  possible)  what  is  the 
substance  employed. 


142  SYSTEMATIC  CASE-TAKING 

4.  Psychical  Functions. — ^The  state  of  the  patient's 
intellect  is  to  be  investigated,  so  far  as  it  concerns  the 
diagnosis  of  medical  diseases.  Is  his  memory  for  recent 
and  for  remote  events  up  to  the  average  ?  Does  he  give 
attention  to  what  is  going  on,  or  does  his  attention 
wander  off  too  readily  ?  Is  his  understanding  or  intelli- 
gence fair  ?     Has  he  any  delusions  or  hallucinations  ? 

Should  he  be  unconscious,  note  if  there  are  any  accom- 
panying symptoms  which  may  assist  in  the  diagnosis 
(see  Appendix  X.). 

Speech. — If  he  is  sufficiently  conscious,  his  command 
of  language  is  to  be  carefully  investigated. 

Ascertain  if  he  can  hear  and  see  sufficiently  well  to 
perceive  the  sound  and  appearance  of  spoken  and 
written  words  respectively.  When  he  speaks,  observe 
if  there  is  any  defect  in  his  voice  (see  Chapter  IV.),  in 
the  distinctness  of  his  articulation,  or  in  the  facility  with 
which  he  can  express  his  thoughts  in  words.  Thus,  he 
may  speak  in  a  clumsy,  awkward  manner,  with  imper- 
fect pronunciation,  especially  of  the  dentals  and  labials 
[slurring  speech) ;  this  is  a  characteristic  of  facial  para- 
lysis, bulbar  paralysis,  and,  when  combined  with  tremor 
of  the  lips  and  tongue,  of  general  paralysis  of  the  insane 
and  of  alcoholism.  A  slow,  measured  speech  (scanning 
speech)  is  a  symptom  of  multiple  sclerosis  and  of  the 
rarer  condition,  Friedreich's  ataxia.  Stammering  is  a 
defect  of  co-ordination  of  the  muscular  acts  involved  in 
speech,  and  a  somewhat  similar  speech  defect  is  observed 
in  chorea  and  hysteria.  Lisping  and  other  similar  defects 
may  be  due  to  habit  or  to  disease  of  the  teeth  or  mouth. 

The  imperfections  of  speech  mentioned  above  are 
examples  of  inefficiency  of  the  organs  of  speech  rather 
than  of  the  mental  faculties,  and  are  spoken  of  generally 
as  anarthria. 


NERVOUS  SYSTEM  143 

Aphasia. — Intelligent  speech  involves  the  active  use 
of  the  mind  in  recalling  memories  of  sounds  (or  written 
signs)  which  have  been  stored  up  in  the  brain  in  the 
process  of  learning  to  understand  language,  to  speak, 
and  to  write.  Disorders  of  speech  which  are  due  to 
disturbance  of  the  mental  functions  and  organs  are 
termed  aphasia.  The  storing-up  of  impressions  of  sound 
and  vision  is  not  a  haphazard  process,  but  proceeds  on 
definite  lines.  Impressions  of  sounds  and  spoken  words 
which  can  be  recalled  as  memories  are  stored  in  a 
"  centre,"  situated  in  the  first  temporo-sphenoidal  con- 
volution, of  the  left  side  in  right-handed  persons,  and  of 
the  right  side  in  the  smaller  number  of  persons  who  are 
left-handed.  A  "  centre  "  for  visual  memories  is  simi- 
larly situated  in  the  left  or  right  angular  gyrus.  In 
the  occipital  lobe  on  both  sides  are  the  primary  centres 
for  vision.  These  centres  are  connected  by  means  of 
association  fibres,  and  are  similarly  in  communication 
with  a  co-ordinating  centre  which  controls  and  regulates 
the  impulses  from  the  above  centres,  resulting  in  spoken 
or  written  language.  The  last-named  centre  is  situated 
in  the  third  frontal  convolution  (Broca's  convolution), 
and  possibly  in  the  second  frontal  as  regards  writing. 
In  right-handed  persons  Broca's  centre  is  in  the  left 
frontal  lobe,  while  in  left-handed  persons  it  is  in  the  right. 
From  Broca's  centre  association  fibres  convey  impulses 
to  both  sides  of  the  brain,  stimulating  the  motor  centres 
concerned  in  the  complex  muscular  actions  of  speech. 

In  order  to  discover  the  situation  of  a  lesion  giving 
rise  to  a  speech  defect,  a  full  and  searching  examination 
of  the  powers  of  speech  of  the  patient  is  to  be  undertaken. 
The  following  outline  of  the  method  of  investigation  may 
be  adopted  and  amplified  : 

(i)  Ask  the  patient  to  pick  up  a  pencil,  strike  a  match, 


144  SYSTEMATIC  CASE-TAKING 

put  out  his  tongue,  etc.  If  he  hears,  but  fails  to  com- 
prehend the  words,  he  has  word  deafness  or  auditory 
aphasia.  (2)  Give  him  similar  directions  in  writing ; 
if  he  cannot  understand,  it  is  word  blindness,  alexia,  or 
visual  aphasia.  These  two  groups  of  cases  indicate  a 
lesion  of  some  portion  of  the  receptive  apparatus — i.e., 
the  cortical  centres  for  storing  auditory  or  visual 
memories,  or  the  fibres  connecting  these  centres  with 
Broca's  convolution.  They  are  therefore  known  as 
"  sensory  aphasia."  (3)  He  cannot  speak  voluntarily 
and  correctly :  motor  aphasia  or  aphemia.  (4)  He 
cannot  write  :  agraphia.  Classes  (3)  and  (4)  result  from 
lesion  of  the  centre  for  the  production  of  the  motor 
impulses  which  produce  speech  (Broca's  centre),  or  of 
the  association  fibres  connected  with  it ;  it  is  therefore 
motor  aphasia  and  motor  agraphia.  Should  he  be  able 
to  write  to  dictation,  but  not  voluntarily,  it  is  sensory 
agraphia.  (5)  He  can  speak  and  write  voluntarily,  but 
makes  mistakes  in  the  use  of  words,  calling  objects  or 
actions  by  wrong  names :  paraphasia,  paragraphia. 
(6)  He  cannot  recognize  familiar  objects  [mind  blind- 
ness) ;  not  only  is  he  unable  to  give  the  name  of  such 
articles  as  watch,  ring,  scissors,  match,  but  he  cannot 
indicate  what  they  are  used  for.  (7)  A  similar  inability 
to  recognize  the  meaning  of  familiar  sounds  is  mind  deaf- 
ness. (8)  Inability  to  recognize  an  object  by  its  general 
characters — e.g.,  its  hardness,  softness,  shape,  roughness, 
smoothness — is  termed  apraxia.  The  groups  of  defects 
(5)  to  (8)  are  due  to  lesions  affecting  not  only  the  centres, 
but  also  or  principally  the  association  fibres  between 
the  different  regions  of  the  brain.  It  is  rare  to  get  a 
case  of  simple  sensory  or  motor  aphasia,  as  in  most  cases 
the  lesion  causes  a  sufficient  mixing  of  symptoms  to 
render  the  diagnosis  difficult. 


APPENDICES 


lo 


03 


o 


o 


E3  CS   ri    3  p 

OS  'H-^'O  ^ 

(U  OJ   u   (u  cl 

i-[  M  eg  -(-I  CTi 

H 


05  '-'  a;>  tj 

»^        Oh^  C  oj 

^  «i  T)      '55  03 .2 

S'Q    cJ  HH    03^  -*;» 

-dH  c3  o  >  0.2J 


^ 

05 

o5 

p< 

U 

u 

Q 

O 

O 

0)  ri  o  oj  c  w 

?<   1J    aj  ^H  ^<-i    ;:< 
O 


■t    r-!  . 


OJ  (u 


w  o 

>  rrt  •+-!  ^ 

O    5     JHJO     W 


g'd    (fl   >    O    03 

O 


O   <" 

JJ  o 


<D 

Xi 

> 

tuD 

K 

••H  <l^    S    <13    t) 

_/  ^  i-i    "      >r^ 


<u 


•     •  4) 

3.52 

««  S  «-<  -2  '-' 

a  .2  3  ^  2f 


i«.2 


OS 


a 
o 
o 


•o 


-^ 

« 

OS 
u 

el 

0) 
T) 

t/5 

cfl 

tn 

CJ 

0 

o 

o 

u 

H 

OS   O 

6 


i;^  ?3  C 


(D 


o.J^ 


a>  S 


o 


03 


03 


O 


O    O 


'5    j3   03 


J3 


be 


<a        d^tn  3  O  ^  '"•^ 


rCj 

bfl 


C/) 


.3  ^" 


—.1—1  i^  05  o3  _j  rs 

d  ^  t-To  PhoSC/3 
O 


2I 


bo 


C/3 


o  a3  O  «  rt  3 


<a 


►5   g 


033   ^—1   QC^   ^ 

5  ei;^.-.  OJ  2?  S 


03. 
O   J-1   {-I   c 


rC  **-•  iXj     •-»->• 

W)0  -^   bfiy    03 
§  bC§   C!   03'«+j 

d  ra+i+^  03^  S 

03 


o 


3^  ex's 
S-2  2  S 


a 


2    43-^ 


o 


•a 

S    03 

C!   ■■ 

03    ^ 


,<« 


T5 

CI 

3 


3    rt   03   Oifl    03    .  .    . 
,Q    O)  -M    O    Cfl    bOrO 


S  "^  ^% 

O  c!  ?i 

o  '-'  o 

o  d 

f  3 


03 


o  w^ 


ft©  - 
fi  &  (9 

o 


148  SYSTEMATIC  CASE-TAKING 

APPENDIX  II 

MICRO-ORGANISMS  IN  THE  URINE 

A  CATHETER  specimen  of  the  urine  is  to  be  obtained 
with  complete  aseptic  precautions.  CentrifugaHze,  or 
allow  it  to  sediment.  Ammoniacal  urine  may  be  heated 
on  a  water-bath  with  dilute  potassium  hydrate  solution 
before  centrifugalizing ;  urates  are  to  be  dissolved  by 
warming.  Smear  a  cover-glass  with  the  sediment,  and 
allow  it  to  dry  in  the  air  at  ordinary  temperature.  Fix 
by  passing  it  three  times  rapidly  through  a  Bunsen 
flame. 

1.  Methylene  Blue. — Add  3  or  4  drops  of  a  5  per  cent, 
solution  of  methylene  blue  in  alcohol  to  a  watchglass 
of  water.  Immerse  the  cover-glass  in  this  dilute  solution 
for  two  or  three  minutes,  wash  in  water,  dry  with  filter- 
paper,  and  mount  in  Canada  balsam.  A  useful  stain  for 
all  urinary  bacteria,  and  chiefly  for  the  gonococcus. 

2.  Gram's  Method, — Add  a  few  drops  of  aniline  oil  to 
about  half  a  test-tubeful  of  water,  shake  thoroughly 
for  about  a  minute,  then  filter  the  emulsion  through  a 
filter-paper  previously  wet  with  water ;  to  a  watchglassf ul 
of  this  aniline  water  add  3  or  4  drops  of  a  7  per  cent, 
solution  of  gentian  violet  in  absolute  alcohol.  Place 
the  cover-glass  smear  in  this  stain  for  two  minutes, 
transfer  it  for  two  minutes  to  Gram's  iodine  solution 
(iodine,  i  gramme ;  potassium  iodide,  2  grammes ; 
water,  300  c.c).  Wash  in  95  per  cent,  alcohol  till  no 
more  colour  comes  away ;  wash  in  water.  Counter- 
stain  for  about  half  a  minute  with  basic  fuchsin  (3  or 
4  drops  of  a  10  per  cent,  alcoholic  solution  of  basic 
fuchsin  in  a  watchglassf  ul  of  water).  Wash  in  water, 
dry  with  filter-paper,  and  mount  in  Canada  balsam. 
By  this  method  the  streptococcus,  staphylococcus,  and 
tubercle  bacillus  (Gram-positive),  are  stained  dark  blue 
or  black  (the  smegma  bacillus  is  not  stained),  while 
the  gonococcus,  Bacillus  typhosus,  and  B.  coli  communis 
(Gram-negative)  are  stained  red. 


APPENDICES  149 

3.  Ziehl-N eelsen  Method. — Pour  a  few  drops  of  carbol 
fuchsin  solution  (fuchsin,  i  gramme ;  alcohol,  10 
grammes  ;  5  per  cent,  aqueous  solution  of  carbolic  acid 
to  100  c.c.)  on  the  cover-slip  smear.  Hold  it  by  a  forceps 
over  a  Bunsen  flame,  and  keep  it  heated  for  two  minutes. 
Wash  in  water  ;  pour  on  it  a  few  drops  of  a  20  per  cent, 
solution  of  nitric  acid,  remaining  for  three  to  five  seconds  ; 
wash  in  water.  Drop  on  60  per  cent,  alcohol  till  the  red 
colour  disappears  ;  wash  in  water.  Counter-stain  with 
dilute  methylene  blue  as  in  (i) ;  wash,  dry,  and  mount 
in  Canada  balsam.  The  tubercle  bacillus  is  best  stained 
by  this  method. 


APPENDIX  III 
WIDAL'S  REACTION 

A  FEW  drops  of  blood  from  a  prick  of  the  patient's  finger 
are  received  in  a  small  glass  capsule.  The  serimi  thus 
obtained  is  diluted  by  means  of  a  diluting  pipette 
with  0-8  per  cent,  sodium  chloride  solution.  A  series 
of  dilutions  are  made  on  glass  slides — viz.,  i  in  5,  i  in  10, 
I  in  25,  and  i  in  50.  Take  an  equal  quantity  of  each  of 
these  dilutions  and  of  a  freshly  prepared  culture  of 
typhoid  bacilli,  and  make  a  series  of  hanging-drop  prep- 
arations of  the  dilution  of  i  in  10,  i  in  20,  i  in  50,  and 
I  in  100.  If  the  serum  is  from  a  typhoid  patient,  the 
bacilli  will  be  motionless  and  clumped  in  less  than  two 
hours,  and  the  lower  dilutions  sooner.  The  reaction 
may  be  reported  positive  if  there  is  distinct  agglutination 
in  a  I  in  50  dilution  in  an  hour. 

This  reaction  is  clinically  almost  restricted  to  typhoid 
fever,  but  it  can  also  be  applied  to  cholera  and  Malta 
fever,  and  to  some  other  bacterial  processes. 


ISO  SYSTEMATIC  CASE-TAKING 

APPENDIX  IV 

WASSERMANN'S  REACTION 

By  bringing  an  antigen  (foreign  organic  extract)  into 
contact  with  the  antibody  present  in  the  serum  of  a 
syphihtic  patient,  complement  is  fixed.  This  is  demon- 
strated by  the  absence  of  haemolysis  on  introducing 
sensitized  corpuscles  to  the  serum  which  has  been  so 
treated. 

Method. — ^The  organic  extract,  as  recommended  by 
Fleming,  is  prepared  by  bruising  in  a  mortar  i  gramme 
of  fresh  hear^  muscle  in  5  c.c.  absolute  alcohol ;  heat  to 
60°  C.  for  ari  nour,  and  incubate  for  twenty-four  hours ; 
the  clear  fluid,  diluted  with  saline  solution,  is  the  extract. 
Into  a  small  glass  tube  (i  inch  long  by  J  inch  diameter) 
4  parts  of  extract  (measured  by  means  of  a  Wright's 
pipette)  are  placed,  and  into  another  similar  tube  are 
placed  4  parts  of  saline  solution  ;  i  part  of  the  serum 
under  examination  is  now  added  to  each  tube,  and 
they  are  placed  in  the  incubator  for  half  an  hour.  A 
similar  control  experiment  is  made  at  the  same  time 
with  non-syphilitic  serum.  Add  i  part  of  a  10  per  cent, 
suspension  of  sheep's  corpuscles  in  saline  to  each  tube, 
and  incubate  for  an  hour  and  a  half.  The  control  tubes 
should  both  show  haemolysis.  If  both  saline  and  extract 
tubes  of  the  suspected  case  show  haemolysis,  the  reaction 
is  negative ;  if  the  extract  tube  shows  no  haemolysis,  while 
the  saline  tube  is  haemolyzed,  the  reaction  is  positive ; 
if  no  haemolysis  occurs  in  either  tube,  the  reaction  is 
indeterminate. 

A  positive  reaction  is  hardly  ever  found  in  health,  and 
rarely  in  any  affection  except  syphilis,  in  which  disease 
it  occurs  in  over  go  per  cent,  of  the  cases.  In  the 
tertiary  and  parasyphilitic  affections  it  also  occurs  in 
the  majority  of  cases. 


APPENDICES  151 


APPENDIX  V 


FREE  HYDROCHLORIC  ACID— QUANTITATIVE 
ESTIMATION 

It  is  chiefly  in  the  examination  of  the  stomach  contents 
that  this  test  is  employed,  and  is  then  regarded  as  a 
measure  of  the  quantity  of  the  gastric  juice  present. 

To  10  c.c.  of  the  filtered  stomach  contents  add  a  few 
drops  of  a  0*5  per  cent,  alcoholic  solution  of  dimethylami- 
doazobenzol ;  free  hydrochloric  acid  causes  the  solution 
to  turn  red.  From  a  burette  run  in  gradually  decinormal 
soda  solution  (4  grammes  NaHO  to  i  litre  water)  till 
the  fluid  is  neutralized,  as  shown  by  the  disappearance 
of  the  red  colour  and  its  replacement  by  a  greenish  yeUow. 
Note  the  quantity  of  soda  solution  expended  :  i  c.c.  of 
decinormal  soda  solution  neutralizes  0*00365  gramme  of 
free  hydrochloric  acid. 


APPENDIX  VI 
TOTAL  ACIDITY  OF  STOMACH  CONTENTS 

The  acidity  of  the  stomach  contents  is  due  to  the 
presence  of  free  hydrochloric  acid,  salts  of  the  mineral 
acids  (chiefly  acid  phosphate),  and  organic  acids.  The 
estimation  of  the  acidity  of  other  fluids — e.g.,  the  urine — 
may  also  be  made  by  the  following  test : 

To  10  c.c.  of  unfiltered  stomach  contents  add,  with 
thorough  shaking,  about  100  c.c.  water  and  a  few  drops 
of  a  I  per  cent,  alcoholic  solution  of  phenolphthalein. 
This  causes  the  solution  to  be  pink  if  alkaline,  and 
colourless  if  acid.  From  a  burette  run  in  decinormal 
soda  solution  (see  Appendix  V.) ;  as  soon  as  the  solution 
begins  to  turn  pink,  note  the  amount  of  soda  solution 
expended.  The  measure  of  acidity  may  be  taken  to  be 
the  quantity  of  soda  solution  required  to  neutralize  10  c.c. 
of  stomach  contents.  During  normal  digestion  the  acidity 
is  between  40  and  60. 


152  SYSTEMATIC  CASE-TAKING 

APPENDIX  VII 
DIAZO    REACTION 

Two  solutions  are  to  be  prepared  :  (i)  a  0-5  per  cent, 
solution  of  sodium  nitrite  in  water  ;  (2)  sulphanilic  acid, 
0*5  gramme ;  hydrochloric  acid,  5  c.c. ;  water,  100  c.c. 
A  couple  of  drachms  of  {2)  with  a  few  drops  of  (i)  are 
shaken  up  in  a  test-tube  ;  add  an  equal  quantity  of  urine, 
and  ammonia  to  alkalinize.  A  positive  reaction  shows  a 
port-wine  colour  with  red  froth. 

This  reaction  is  almost  always  found  in  typhoid  fever 
in  the  second  and  third  week ;  it  is,  however,  given  in 
cases  of  active  tuberculosis,  and  often  in  pneumonia, 
measles,  scarlet,  and  other  fevers. 

APPENDIX  VIII 
RUSSO'S  METHYLENE-BLUE  REACTION 

To  4  or  5  c.c.  of  filtered  urine  add  4  drops  of  a  i  in 
1,000  watery  solution  of  methylene  blue.  Shake  the 
tube,  and  if  the  patient  is  suffering  from  typhoid  fever 
an  emerald-green  colour  appears  ;  in  negative  cases  there 
is  scarcely  any  colour. 

APPENDIX  IX 
ELECTRICAL  EXAMINATION 

It  is  almost  exclusively  in  disease  of  the  lower  segment 
of  the  motor  tract  that  examination  by  means  of  elec- 
tricity is  of  use  ;  the  interrupted  and  the  continuous 
currents  are  both  to  be  used.  (The  examination  by 
X  rays  is  not  here  considered.) 

The  region  to  be  examined  is  first  submitted  to  the 
interrupted  or  faradic  current,  which  stimulates  the 
motor  nerves.  A  large  terminal  is  placed  on  an  indif- 
ferent region — e.g.,  between  the   shoulder-blades — and 


APPENDICES  153 

a  smaller  one  is  used  to  demonstrate  the  contracting 
power  of  the  various  muscles,  by  placing  it  near  the 
spot  where  the  nerve  enters  the  muscle  in  question 
[motor  -point),  and  also  over  the  trunk  of  the  nerve. 
Observe  the  minimum  power  of  current  which  produces 
a  muscular  contraction,  and  note  if  there  is  any  differ- 
ence in  contractility  between  the  sides  of  the  body. 

The  continuotis  or  galvanic  current  is  next  to  _  be 
employed.  The  management  of  the  terminals  is  similar 
to  that  of  the  faradic  current,  but  the  muscle  as  well 
as  the  nerve  responds  to  this  stimulus.  The  negative 
electrode  or  cathode  is  first  to  be  used,  noting  by  means 
of  the  galvanometer,  in  milliamperes,  the  smallest 
current  which  produces  a  current  on  closing  and  on 
opening  the  circuit.  Also,  the  same  observation  is  to  be 
made  with  the  positive  electrode  or  anode  in  use.  Here 
also  the  effects  of  the  current  on  both  sides  of  the  body 
are  to  be  compared. 

Normally  the  muscle  contracts  most  readily  with 
cathodal  closure.  The  anodal  opening  and  closing  con- 
tractions require  a  stronger  current,  and  the  cathodal 
opening  contraction  is  the  most  difficult  to  obtain. 
This  may  be  expressed  by  the  formula  : 

C.C.C.>A.C.C.>A.O.C.>C.O.C. 

In  disease  of  the  nervous  system  affecting  the  nutrition 
of  the  nerves  and  muscles,  one  finds  alterations  in  the 
character  of  the  contraction  and  in  the  order  in  which 
currents  of  different  characters  and  strength  give  rise 
to  muscular  contraction  (qualitative  changes).  Also  one 
finds  changes  in  the  degree  of  activity  of  the  muscular 
contractions  (quantitative  changes).  A  characteristic 
series  of  alterations  of  the  electrical  reactions  is  known 
as  the  reaction  of  degeneration.  When  complete,  this 
change  consists  of  loss  of  response  to  the  faradic  current, 
with  increased  response  of  the  muscle  to  galvanic  stimu- 
lation. The  contraction,  however,  while  more  readily 
produced  by  the  continuous  current,  is  sluggish  in  its 
onset,  and  usually  responds  more  easily  to  the  anodal 
than  to  the  cathodal  closing  current. 


APPENDIX  X 


STATES  OF 


Symptoms. 

Ursemia. 

Opium-Poisoning. 

Alcoholic 
Poisoning. 

Apoplexy. 

z.  Mode  of 

Usually  gra- 

Gradual,    but 

Gradual,     but 

Often  sudden 

onset 

dual 

rapid 

rapid 

2.  Degree  of 

Deep  coma ; 

Deep      narco- 

As  a  rule  can 

Cannot  be  roused 

insensi- 

cannot  be 

s  is  ;    can 

be  roused 

bmty 

roused 

usually      be 
roused  with 
difi&culty 

3.  Aspect . . 

Pallid  ;  per- 

Face   dusky, 

Flushed     or 

Flushed,  cyanosed. 

haps  oede- 

livid,     or 

cyanosed ; 

or  grey 

ma  ;     has 

cyanosed 

rarely  pale 

the  aspect 

of      renal 

disease 

4.  Ck)n(iition 

Convulsions, 

Sometimes 

Twitchings 

Hemiplegia      com- 

of    the 

twitching. 

convulsions 

or  tremor 

monly. 

muscles 

or  rigidity; 
sometimes 
paralysis 

5.  Pulse   .. 

Infrequent  ; 

Full    and    in- 

Full;  frequent 

Full ;     infrequent ; 

high    ten- 

frequent 

of  high  tension 

sion 

6.   Respira- 

Laboured; 

Slow;    la- 

Deep;     slow ; 

Slow  ;    stertorous  ; 

tion 

noisy 

boured  ; 

sometimes 

sometimes 

noisy ;  often 

stertorous 

Cheyne-Stokes 

C  h  e  y  n  e  - 

Stokes 

7.  Tempera- 

Normal    or 

Normal 

Usually     sub- 

Raised 

ture 

subnormal; 
raised    in 
convulsive 
attacks 

normal 

8.  SmeU  of 

Heavy,     of- 

Odour     of 

Odour    of    al- 

No    distinctive 

the  breath 

fensive 

opium 

cohol,    with 
foetor 

odour 

9.  Pupils  . . 

Inconstant ; 

Markedly   and 

Dilated 

Variable ;     usually 

may       be 

equally  con- 

dilated ;    always 

widely  di- 

tracted 

inactive 

lated  or  of 

medium 

size 

ro.  Other 

Convulsions 

Skin   dry   (ex- 

History      of 

Patients  commonly 

prominent 

usually  oc- 

cep t     t  0  - 

alcoholic 

elderly    males. 

symptoms 

cur.  Urine 

wards       the 

excess.      Ir- 

History of  gout, 

scanty   or 

end)    and 

ritable    or 

arterio  -  sclerosis, 

suppress- 

warm 

abusive 

lead-poisoning. 

ed.    Albu- 

when roused 

Family  history 

min     pre- 

may   indicate 

I 

sent 

atheroma. 
Conjugate  devia- 
tion   often    pre- 
sent,    the     eyes 
looking     toward 
the      lesion      in 

most  cases 

UNCONSCIOUSNESS 


Meningitis. 


Diabetes. 


Gradual 

Cannot  be  roused 

Cyanosed  or  pale 


Limbs  often  rigid 
and  flexed.  Often 
convulsions 


Infrequent ;  may  be 
rapid  if  tempera- 
ture raised 

May  be  frequent  if 
temperature 
raised 


Often  raised 


No  distinctive  odour 


Inconstant 


Patients  commonly 
youthful.  Head- 
ache ;  vomiting  ; 
retraction  of  head 
in  some  cases. 
History  of  ear 
disease,  tubercle. 
Diplococcus  intra- 
cellularis  in  fluid 
(obtained  by  lum- 
bar puncture) 
in  cases  of  epi- 
demic cerebro- 
spinal meningitis 


Hysteria. 


Gradual   or  sud- 
den 
Cannot  be  roused 


Cyanosed  or  pale 


Unaffected 


Normal  and  full 


Laboured  and 
rapid  ("air 
hunger  ") 


Subnormal 


Sweet,  fruity 
("like  over- 
ripe apples  ") 

Inactive 


Most  severe  in 
youthful  pa- 
tients. Head- 
ache, vomiting ; 
drowsiness  of- 
ten precedes 
coma.  Sugar  in 
the  vurine 


May  follow  a  con- 
vulsion 
Can  be  roused 


Flushed 


Epileptiform      con- 
vulsions common 


Syncope. 


Unaffected 


Rapid,  but  not  ster- 
torous 


Unaffected 


Unaffected 


Equal ;  normal  size 
or  dilated  ;  react 
to  light 


Sudden 

Roused  by  stim- 
ulating the  cir- 
culation 


Pale 


Unaffected 


Weak  or  absent 


Shallow  and  al- 
most imper- 
ceptible, or 
sighing 

Unaffected 


Unaffected 


Widely  dilated 


Almost  exclusively 
in  females.  Coma 
resembles  deep 
sleep,  but  caused 
by  conditions  i 
which  prevent 
normal  sleep 
(emotional  ex- 
citement, etc.). 
Eyelids  are  kept 
closed,  and  re- 
sist attempts  to 
open  them 


Females 

more 

commonly     af- 

fected 

than 

males. 

Eyes 

often 

remain 

open 

156  SYSTEMATIC  CASE-TAKING 

APPENDIX  XI 

PARALYSIS  ACCOMPANIED  BY   (A)   SPASM  AND 
(B)  ATROPHY  OF  THE  MUSCLES 

A.  Spastic  Paralysis  (supranuclear  or  upper  neuron  lesion). 

I.  Disease  of  the  spinal  cord  : 

1.  Transverse  interruption  of  the  cord  : 

(i)  Compression  of  the  cord : 

[a)  Caries  of  the  vertebrae  (Pott's 
disease). 

(6)  Tumours  of  the  meninges  and 
of  the  vertebrae  (carcinoma, 
sarcoma,  syphilis). 

(c)  Pachymeningitis  (especially 
hypertrophic  form). 

{d)  Aneurism  of  the  aorta  or  of  its 
branches. 

[e)  Traumatism  of  vertebral  col- 
umn, and  intrameningeal 
haemorrhage. 

(2)  Myelitis,  acute  and  chronic,  trans- 

verse or  diffuse. 

(3)  Haemorrhage  into  the  cord. 

2.  Sclerotic  changes  in    the  upper  segment 

of  the  motor  tract : 

(i)  Primary  lateral  sclerosis. 

(2)  Hereditary  spastic  paraplegia. 

(3)  Lateral  sclerosis  complicated  with 

other  lesions  of  the  cord  : 
(a)  Amyotrophic   lateral   sclerosis 

(Charcot's  disease). 
(6)  Ataxic  paraplegia. 

(c)  Primary     combined     sclerosis 

(Putnam  and  Dana). 

(d)  Multiple  (disseminate,  insular) 

sclerosis. 

(e)  Syringomyelia. 
(/)  PeUagra. 


APPENDICES  157 

II.  Disease  of  the  brain  : 

1.  Lesions  of  the  circulation  : 

(i)  Haemorrhage. 

(2)  Embolism. 

(3)  Thrombosis. 

2.  Tumours. 

3.  Degenerative  and  inflammatory  changes  : 

(i)  Multiple  sclerosis. 

(2)  General  paralysis  of  the  insane. 

(3)  Cerebellar  heredo-ataxia. 

III.  Functional  disturbance  (hysteria,  neurasthenia, 
"  railway  spine  "). 

B.  Flaccid  Paralysis  (lower  neuron  lesion). 
I.  Disease  of  the  brain  and  spinal  cord: 

1.  Chronic  degenerations : 

(i)  Progressive  spinal  muscular  atrophy. 

(2)  Bulbar  paralysis. 

(3)  Ophthalmoplegia. 

(4)  Friedreich's  ataxia. 

2.  Acute  inflammations : 

(i)  Infantile   paralysis    (acute   anterior 

polio-encephalo-myelitis) . 
(2)  Landry's  paralysis. 

3.  Traumatism  :  injury  to  cervical  or  lumbar 

enlargement. 

II.  Disease  of  the  peripheral  nerves  : 

1.  Lesions  of  the  cranial  motor  nerves. 

2.  Lesions  of  the  spinal  motor  nerves. 


158  SYSTEMATIC  CASE-TAKING 

APPENDIX  XII 

TESTS  FOR  TUBERCULOSIS 

I.  Calmette's  Test. — One  drop  of  a  0*5  per  cent,  solu- 
tion of  tuberculin  is  placed  at  the  inner  side  of  the 
conjunctival  sac.  A  positive  reaction,  occurring  within 
six  hours,  consists  in  swelling  and  redness  of  the  lachry- 
mal tubercle,  and  congestion  and  oedema  of  the  con- 
junctiva. 

The  test  is  positive  in  most  cases  of  active  or  latent 
tuberculosis,  and  in  a  number  of  apparently  healthy 
cases.  In  chronic  cachectic  tuberculous  patients  and 
in  virulent  and  extensive  lesions  the  reaction  is  usually 
negative. 

2.  Von  Pirquefs  Test. — ^The  skin  is  scarified  over  a 
small  area,  and  an  ointment  of  25  per  cent.  Koch's  old 
tuberculin  is  rubbed  in.  A  positive  reaction  is  the 
appearance  in  a  few  hours  of  a  deep  red  papule,  which 
persists  for  some  days. 

It  is  positive  in  very  similar  conditions  to  those  in 
which  Calmette's  test  is  positive. 

3.  Moro's  Test. — ^A  morsel  about  the  size  of  a  pea 
of  a  50  per  cent,  ointment  of  Koch's  old  tubercuHn  is 
rubbed  on  the  skin.  After  twelve  or  perhaps  twenty- 
four  hours  a  papular  or  pustular  eruption  appears, 
when  the  reaction  is  positive. 

The  reaction  occurs  under  similar  circumstances  to 
those  just  mentioned. 


INDEX 


Abdomen,  84 

auscultation  of  the,  89 
enlarged  veins  in,  84 
movements  of  the,  86 
palpation  of,  85 
percussion  of  the,  88 
shape  of  the,  86 
topography  of,  84 
Accidental  murmurs,  69 
Acetone  in  the  urine,  107 
Acidity,    estimation   of   total, 

151 

Adventitious  sounds,  57 
iEgophony,  57 
Age,  4 

Agraphia,  144 
Albuminuria,  102 

functional,  104 
Alexia,  144 
AUocheiria,  135 
Alternate  paralysis,  119 
Anacrotic  pulse,  30 
Anaesthesia,  135 

dissociated,  135 
Analgesia,  135 
Anarthria,  142 
Anasarca,  23 
Angle  of  Ludwig,  36 
Ankle  clonus,  131 
Ankle- jerk,  131 
Ape-hand,  124 
Apex-beat,  62 

displacements  of  the,  63 
Aphasia,  143 

auditory,  144 

motor,  144 

sensory,  144 

visual,  144 


Aphemia,  144 
Aphonia,  46 
Apraxia,  144 
Arc,  reflex,  129 
Area,  aortic,  70 

mitral,  70 

of  cardiac  dulness,  63 

of  superficial  cardiac  dul- 
ness, 50 

pulmonary,  70 

tricuspid,  70 
Argyll- Robertson  pupil,  133 
Arm,  paralysis  of  the,  124 

reflexes,  131 
Arteries,  examination  of  the, 

75 

tension  of  the,  30 
Aspect,  16 
Ataxia,  128 
Ataxic  gait,  23 
Auditory  aphasia,  144 
Auscultation,  53 

of  the  abdomen,  89 
Auscultatory  percussion,  90 
Azoturia,  109 

Bell  sound,  52 

Bell's  phenomenon,  123 

Bial's  test,  108 

Bile  in  the  urine,  109 

Bilious  vomiting,  94 

Biot's  respiration,  44 

Blindness,  140 

mind,  144 

word,  144 
Blisters,  20 
Blood  cells,  78 

examination  of  the,  78 


159 


i6o 


INDEX 


Blood  in  the  urine,  104,  109 

vomited,  94 
Box  note,  50 
Bradycardia,  33 
Breakfast,  test,  92 
Breathing,altered  rhythm  of,  43 

aphoric,  56 

bronchial,  54 

broncho-vesicular,  55 

cavernous,  56 

Cheyne-Stokes,  44 

cog-wheel,  56 

puerile,  54 

tracheal,  54 

tubular,  56 

vesicular,  54 
Breath  sounds,  54 

metamorphosed,  56 
Broadbent's  law,  123 

sign,  65 
Broca's  centre,  143 
Bronchophony,  57 
Bruit  de  diable,  77 

Capillaries,  examination  of  the, 

Caput  medusae,  84 
Carbonate  of  lime  in  the  urine, 

115 
Cardiac  dulness,  area  of,  63 
superficial,  50 
Cardio-pulmonary  sounds,  75 
Case-taking,  method  of,  i 
Casts  in  the  urine,  112 
Cephalalgia,  9 
Cerebral  paraplegia,  119 
Chest,  alar,  39 

barrel,  39 

emphysematous,  39 

flat,  39 

funnel,  38 

movements  of  the,  62 

rickety,  38 
Chest- wall,  retraction  of  the,  64 
Cheyne-Stokes  respiration,  44 
Chlorides,  iii 
Choked  disc,  137 
Cholesterin,  115 
Circulatory  system,  62 
Claw-hand,  125 


Clonic  spasms,  127 
Coli,  bacillus,  112 
Colour  index,  79 

of  the  skin,  1 7 
Conjugate  deviation,  122 
Convulsive  fits,  128 
Corrigan's  pulse,  31 
Cough,  45 

Cracked-pot  sound,  52 
Crepitatio  indux,  58 

redux,  58 
Crisis,  27 

Crossed  paralysis,  119 
Cupped  disc,  137 
Cyanosis,  17 
Cyrtometer,  38 
Cystin,  115 

Deafness,  mind,  144 

word,  144 
Deltoid  paralysis,  124 
Dermatitis,  21 
Dermographism,  134 
Desquamation,  22 
Deviation,  conjugate,  122 

secondary,  122 
Diacetic  acid  in  the  urine,  107 
Diaphragm  paralysis,  124 

sign,  47 
Diastolic  murmurs,  72 
Diazo  reaction,  152 
Dicrotic  pulse,  30 
Diminished  resonance,  51 
Diplegia,  119 
Diplopia,  122 
Disc,  choked,  137 

cupped,  137 
Dissociated  anaesthesia,  135 
Double  vision,  122 
Dropped  foot,  23 
Dulness,  49 

area  of  cardiac,  63 

ofjsuperficial  cardiac, 

50 
Duroziez's  double  murmur,  76 

Dyspnoea,  41 

stertorous,  44 

Ecchymoses,  21 

Electrical  examination,  152 


INDEX 


i6i 


Ellis's  line,  51 
Emprosthotonos,  22,  126 
Endocardial  murmurs,  69 
Environment,  5 
Eosinophilia,  81 
Epigastric  pulsation,  64 
Epileptiform  attacks,  128 
Episternal  pulsation,  64 
Epithelial  cells  in  the  urine, 

113 

Erb's  paralysis,  124 
Eruptions,  18 
Erythema,  18 
Examination,  general,  15 
Exocardial  sounds,  74 
Expression  of  the  face,  16 
Extra  systole,  34 

Face,  expression  of  the,  16 

pain  in  the,  10 
Facial  paralysis,  123 
Faecal  vomiting,  94 
Faeces,  96 
False  image,  122 
Family  history,  2 
Fehling's  test,  105 
Fermentation  test,  106 
Festinating  gait,  23 
Fever,  26 

Fibrillary  twitchings,  127 
Field  of  vision,  139 
Filatow's  spots,  19 
Fits,  convulsive,  128 
Flaccid  paralysis,  119,  157 
Flashes  of  light,  139 
Flint's  murmur,  73 
Fluid  vein,  69 
Foot-drop,  120 
Formication,  135 
Fremitus,  vocal,  47 
Friction,      pleuro  -  pericardial, 
60,  75 

sound,  59 

sounds,  pericardial,  74 
Functional  albuminuria,  104 

murmurs,  69 

Gait,  22 

ataxic,  23 
festinating,  23 


Gait,  paretic,  23 

pseudo-ataxic,  23 

reeling,  23,  129 

spastic,  23 

stamping,  23,  129 

steppage,  23,  120 

stumbling,  129 
Gallop  rhythm,  68 
Garland's  line,  51 
Gastroptosis,  89 
Girdle  pain,  136 
Glands,  82 
Glycosuria,  105 
Gram's  method,  148 

Habits,  6 

Haematemesis,  94 

Haematuria,  104,  109 

Haemic  murmurs,  69 

Haemoglobinuria,  no 

Haemoglobin  value,  78 

Haemorrhages,  21 

Hand,  paralysis  of  the,  124 

Harrison's  sulcus,  38 

Headache,  9 

Head,  retraction  of  the,  126 

Hearing,  defects  of,  140 

Heart  sounds,  66 

reduplication  of  the, 
67 

Hemianopsia,  139 

Hemiplegia,  120 

Herpes,  20 

Hippus,  133 

History,  family,  2 

of  the  present  af£ection,^6 
personal,  3  -vj 

Hoarseness,  46 

Hydrochloric  acid,  estimation 
of,  151 

Hyperaesthesia,  8,  135 

Hyperalgesia,  135 

Hyper  chlorhydria,  93 

Hyperpyrexia,  27 

Hyper-resonance,  49 

Hypochlorhydria,  93 

Image,  false,  122 

true,  122 
Inco-ordination,  128 

II 


l62 


INDEX 


Indican,  iii 

Inflammation  of  the  skin,  21 
Intellectual  functions,  142 
Intermittent  temperature,  26 
Intestines,  examination  of,  95 

Jaffe's  test,  iii 
Jaw- jerk,  131 
Jaw  paralysis,  123 

Kidneys,  examination  of,  97 
Knee-jerk,  130 
Koplik's  spots,  19 

Language,  defects  of,  142 
Legal's  test,  107 
Leucin,  115 
Leucocytosis,  81 
Light,  flashes  of,  139 
Lineae  albicantes,  85 
Line,  anterior  axillary,  36 

Ellis's,  51 

Garland's,  51 

mamillary,  36 

mid-axillary,  36 

midsternal,  36 

nipple,  36 

parasternal,  36 

posterior  axillary,  36 

scapular,  36 

side-sternal,  36 

spinal,  36 
Litten's  sign,  47 
Liver,  enlargement  of,  96 

examination  of,  96 
Locomotive  pulse,  28 
Loss  of  voice,  46 
Ludwig,  angle  of,  36 
Lymphocytosis,  81 
Lysis,  27 

McBurney's  point,  13 

Macules,  19 

Metallic  tinkling,  60 

Meteorism,  86 

Method  of  case-taking,  i 

Micro-organisms  in  the  urine, 

148 
Microscopical    examination  of 

the  urine,  112 


Mind  blindness,  144 

deafness,  144 
Monoplegia,  121 
Motor  aphasia,  144 

tract,  117 
Movable  pulse,  28 
Movement,  defects  of,  116 

sense  of,  136 
Movements,  abolished,  118 

disorderly,  128 

increased,  125 

of  the  abdomen,  86 

of  the  chest,  62 

weakened,  118 
Murmur,  character  of,  74 

Duroziez's  double,  76 

Flint's,  73 

position  of,  70 

time  of  the,  71 

transmission  of,  73 
Murmurs,  accidental,  69 

diastolic,  72 

endocardial,  69 

functional,  69 

haemic,  69 

systolic,  71 
Muscae  volitantes,  138 
Muscle  sense,  136 

Nasal  voice,  46 
Neck,  pulsations  in  the,  65 
Nervous  system,  116 
Neuritis,  optic,  137 
Neuro-retinitis,  138 
Nun's  murmur,  77 
Nystagmus,  127 

Occupation,  5 
Oculo-motor  paralysis,  122 
Opisthotonos,  22,  126 
Optic  atrophy,  137 

neuritis,  137 
Orthopnoea,  22 
Orthotonos,  22,  126 
Oxalate  of  lime  in  the  urine,  114 

Pain,  8,  135 
girdle,  136 
in  the  abdomen,  12 
in  the  arms,  14 


INDEX 


163 


Pain  in  the  face,  10 

in  the  gluteal  region,  13 

in  the  legs,  14 

in  the  neck,  10 

in  the  throat,  10 

in  the  thorax,  10 

in  the  vertebral  column,  1 1 
Palpation  of  abdomen,  85 
Papillitis,  137 
Papules,  19 
Paraesthesia,  8,  135 
Paragraphia,  144 
Paralysis,  alternate,  119 

crossed,  119 

Erb's,  124 

facial,  123 

flaccid,  119,  157 

oculo-motor,  122 

of  the  arm,  124 

of  deltoid,  124 

of  diaphragm,  124 

of  the  hand,  124 

of  lower  jaw,  123 

of  serratus  magnus,  124 

of  sterno-mastoid,  123 

of  the  thigh,  125 

of  the  tongue,  25 

spastic,  118,  156 
Paraphasia,  144 
Paraplegia,  119 

cerebral,  119 
Paretic  gait,  23 
Parkinson's  mask,   16 
Pectoriloquy,  57 

whispering,  57 
Peeling,  22 

Pendulum  rhythm,  67 
Percussion,  48 

auscultatory,  90 

of  the  abdomen,  88 
Pericardial  friction  sounds,  74 

splashing,  75 
Personal  history,  3 
Petechias,  21 
Phosphaturia,  114 
Physical  signs,  7 
Pigeon  breast,  38 
Pimples,  20 

Pleuro-pericardial  friction,  60, 
75 


Pleurosthotonos,  22,  126 
Polyaesthesia,  135 
Position  of  murmur,  70 

sense  of,  136 
Posture,  22 
Premature  systole,  34 
Present    affection,    history    of 
the,  6 

condition,  7 
Pressure  sensibility,  134 
Previous  illnesses,  6 
Priapism,  134 
Projectile  vomiting,  92 
Pseudo-ataxic  gait,  23 
Psychical  functions,  142 
Ptosis,  122 

Pulmonary  region,  49 
Pulsation,  epigastric,  64 

episternal,  64 
Pulsations  in  the  neck,  65 
Pulse,  28 

anacrotic,  30 

bigeminal,  34 

collapsing,  31 

Corrigan's,  31 

dicrotic,  30 

frequent,  33 

infrequent,  33 

intermittent,  33 

large,  34 

locomotive,  28 

movable,  28 

slow,  33 

small,  34 

trigeminal,  34 

volume  of  the,  34 
Pulsus  alternans,  35 

celer,  31 

inter cidens,  33 

magnus,  34 

paradoxus,  35 

parvus,  34 
Pupil,  Argyll-Robertson,  133 
Pus  in  the  urine,  104,  112 
Pustules,  20 
Pyrexia,  26 
Pyuria,  104,  112 

Rales,  58 
Rash,  1 8 


1 64 


INDEX 


Reaction,  diazo,  152 

Russo's  methylene-blue, 
152 

Wassermann's,  150 

Widal's,  149 
Rectum,  examination  of,  95 
Red  blood  cells,  78 
Red  rash,  18 

Reduplication    of    the    heart- 
sounds,  67 
Reeling  gait,  23 
Reflex  arc,  129 

corneal,  132 

cremaster,  132 

gluteal,  132 

inguinal,  132 

light,  132 

palatal,  132 

patellar,  130 

pharyngeal,  132 

plantar,  132 

pupil,  132 

scapulo-humeral,  131 

vasomotor,  133 
Reflexes,  129 

abdominal,  132 

complex,  132 

deep,  130 

of  arm,  131 

of  bladder,  133 

of  rectum,  133 

skin,  131 

superficial,  131 

tendon,  130 

visceral,  132 
Regions,  thoracic,  37 
Remittent  temperature,  26 
Resonance,  48 

amphoric,  52 

diminished,  51 

increased,  50 

metallic,  52 

skodaic,  50 

vocal,  57 

Williamson's  tracheal,  52 
Respiration,    altered    rhythm 

of,  43 
Biot's,  44 
Cheyne-Stokes,  44 
Respiratory  system,  41 


Retinitis,  138 

Retraction  of  the  chest-wall, 
64 

of  the  head,  126 
Rhonchi,  58 
Rhythm,  gallop,  68 

of  respiration,  altered,  43 

pendulum,  67 
Rickety  rosary,  38 
Rigors,  127 
Risus  sardonicus,  126 
Roseola,  19 

Russo's    methylene-blue    re- 
action, 152 

Saturday-night  palsy,  120 
Scotoma,  139 
Secondary  deviation,  122 
Semilunar  space,  Traube's,  50 
Sensory  aphasia,  144 

functions,  134 
Serratus  magnus  paralysis,  124 
Sex,  4 

Shape  of  the  abdomen,  86 
Sign,  Babinski's,  132 

Broadbent's,  65 

Chvostek's,  126 

diaphragm,  47 

Kernig's,  126 

Litten's,  47 

Romberg's,  129 

Westphal's,  130 

Wintrich's,  52 
Signs,  physical,  7 
Skin,  colour  of  the,  17 

inflammation  of  the,  21 
Skodaic  resonance,  50 
Smell,  defects  of,  141 
Snoring,  44 
Souffle  voile,  56 
Sound,  bell,  52 

cracked-pot,  52 

friction,  59 
Sounds,  adventitious,  57 

altered  quality  of,  68 

breath,  54 

cardio-pulmonary,  75 

exocardial,  74 

heart,  66 

pericardial,  74 


INDEX 


65 


Sounds,  succussion,  60 

voice,  57 
Spasm,  tonic,  126 
Spasms,  clonic,  127 
Spastic  gait,  23 

paralysis,  118,  156 
Speech,  defects  of,  142 

scanning,  142 

slurring,  142 
Sphygmograph,  28 
Sphygmomanometer,  29 
Splashing,  pericardial,  75 
Spleen,  examination  of,  97 
Sputum,   examination  of  the, 
61 

tubercle  bacilli  in,  61 
Squint,  122 
Stammering,  142 
Stamping  gait,  23 
Steppage  gait,  23,  120 
Stereognosis,  136 
Sterno-mastoid  paralysis,  123 
Stertorous  dyspnoea,  44 
Stomach,  examination  of  the, 

89 

contents,   examination  of 
the,  92 
Strabismus,  122 
Strawberry  tongue,  25 
Strength,  sense  of,  136 
Stridor,  57 

Subt5niipanitic  note,  49 
Succussion  sounds,  60 
Sugar  in  the  urine,  105 
Supersecretion,  93 
Symptoms,  objective,  7 

subjective,  7 
Systole,  extra,  34 

premature,  34 
Systolic  murmurs,  71 

Tache  cerebrale,  134 
Tachycardia,  33 
Tactile  sensibility,  134 
Taste,  defects  of,  141 
Temperature,  26 

intermittent,  26 

remittent,  26 
Tension  of  the  arteries,  30 
Test,  Bial's,  108 


Test,  breakfast,  92 

Calmette's,  158 

Fehling's,  105 

Gmelin's,  109 

Giinzburg's,  93 

haemin,  no 

Heller's  (albumin),  102 
(blood),  109 

Jaffe's,  III 

Legal's,  107 

Mohr's,  112 

Moro's,  158 

murexide,  in 

Uffelmann's,  93 

Von  Jaksch's,  106 

Von  Pirquet's,  158 
Tests  for  tuberculosis,  158 
Tetany,  126 
Thermal  sense,  136 
Thigh,  paralysis  of  the,  125 
Thorax,  the,  36 
Thrill,  65 
Throat  affections,  147 

pain  in  the,  10 
Tongue,  24 

paralysis  of  the,  25 

strawberry,  25 

tremor  of  the,  25 
Tonic  spasm,  126 
Torticollis,  126 

Total  acidity,  estimation  of ,  151 
Touch,  134 

Traube's  semilunar  space,  50 
Tremor,  127 

of  the  tongue,  25 
Trichterbrust,  38 
Trismus,  126 
True  image,  122 
Tube-casts,  112 
Tubercle  bacilli  in  sputum,  61 
Tuberculosis,  tests  for,  158 
Twitchings,  fibrillary,  127 
Tympanitic  note,  49 
Tyrosin,  115 

Uffelmann's  test,  93 
Unconsciousness,   states  of, 

154,  155 
Urates,  114 
Urea   108 


1 66 


INDEX 


Uric  acid,  iii 

Urine,  acetone  in  the,  107 
albumin  in  the,  102 
bile  in  the.  109 
blood  in  the,  104,  109 
carbonate  of  lime  in  the 

115 

casts  in  the,  1 12 

diacctic  acid  in  the,  107 

epithelial  cells  in  the,  113 

examination  of,  99 

micro-organisms  in  the, 
148 

microscopical  examina- 
tion of  the,  112 

naked-eye  examination  of 
100 

odour  of.  100 

oxalate  of  lime  in  the.  114 

phosphates  in  the,  114 

pus  in  the.  104 

quantity  of.  102 

reaction  of,  100 

specific  gravity  of.  loi 

sugar  in  the.  105 

translucency,  100 

Veiled  puff.  56 
Vein,  fluid.  69 

Veins,  examination  of  the,  76 
in  abdomen,  enlarged,  84 
Venous  hum.  77 


Vesicles,  20 
Vibices,  21 
Vision,  137 

double,  122 

field  of.  139 
Visual  aphasia,  144 
Vocal  fremitus,  47 

resonance,  57 
Voice,  alterations  in  the,  46 

loss  of,  46 

nasal,  46 

sounds,  57 

weakness  of  the,  47 
Vomiting,  90 

bile,  94 

blood,  94 

faecal,  94 

projectile,  92 

Wassermann's  reaction,  150 

Weakness  of  the  voice,  47 

Wheals,  20 

Whispering  pectoriloquy,  57 

Widal's  reaction,  149 

Wintrich's  sign,  52 

Word  blindness,  144 

deafness.  144 
Wrist-drop.  120 

Xanthin,   115 

Ziehl-Neelsen  method,  T49 


THE   END 


Baitltire,  Timiaii  &*  Cox,  8,  Henrietta  Strett,  Ccvent  Garden 


I' 


'/v  .J<;v 


V\i 


c 


asc 


-x.^ 


vrv 


\ 


